The Role

As a Clinical Guide, you'll be responsible for providing clinical review of cases using standard criteria to determine the medical appropriateness of inpatient and outpatient services; while supporting our members through assessment, care and conservation. You'll serve as an advocate for our members, coordinating care and ensuring they have the necessary resources and support to achieve their health goals (recovering from an illness, improving quality of life, overall well-being, etc.) 

Our Clinical Guide is committed to integrity and excellence and empowering members to confidently navigate the healthcare system and live healthier lives.  Our ideal Clinical Guide is caring, compassionate and solutions-oriented, and is enthusiastic about providing an outstanding experience for Devoted Health’s members.

Qualifications

Required skills and experience: 

• An unrestricted Registered Nurse (RN)  license with a minimum of 4 years RN experience
• An unrestricted, Licensed Vocational Nurse (LVN) license with an advanced degree, and applicable years of experience within UM
• A minimum of 3 years experience doing utilization management at a health plan
• Ability to work rotating weekends
• Please note, this role will have specific shift requirements
• Ability to work the schedule of Tuesday - Saturday 8:30am - 5:00pm EST

Desired skills and experience:

• Ability to work in a startup, fast paced environment 
• The ability to comfortably multi- task: you’ll be listening, talking and typing all at the same time
• Team player mentality with a can-do attitude
• Understanding of CMS guidelines and MA requirements
• Adaptability and comfort in a dynamic, startup environment
• Transparency in your work - what’s going well and what’s not
• A desire to make a change in the healthcare experience: you love to serve and make a difference
• Proven success in building relationships
• The ability to adjust your tone and approach to different people
• The ability to articulate and break down complex information

Your Responsibilities and Impact will include:

• Engage with members and understand their needs, using technology and data to better understand the member and any unspoken needs
• Performs initial, concurrent, and discharge reviews of all cases, including: using medical guidelines to determine the medical appropriateness of inpatient and outpatient services; assessing, interpreting, and responding to the needs or requirements of patients; identifying, escalating and resolving complex cases or issues as required.
• Reviews current charts for appropriateness and correct admission status (inpatient, observation, bedded outpatients).
• Alerts and collaborates with appropriate leadership concerning patients who do not meet medical appropriateness criteria.
• Obtains admission and continued stay certification or recertification.
• Communicates with an attending physician regarding patients who do not meet criteria in order to identify additional documentation needs or potential status change.
• Coordinates care and discharge planning. Makes arrangements for appropriate post-hospital care, including physical and behavioral medicine, transportation, equipment, home health care, etc.
• Identifies, documents and communicates potential quality assurance or risk management issues as appropriate.
• Conduct holistic assessment to identify comorbid conditions, ED/ hospitalization history, medications, psycho-social factors, and member values and preferences
• Collaborate with our PCP partners
• Develop care plans in partnership with members and their caregivers - problems, goals, interventions - continuously evaluating the member’s progress
• Work closely with Local Service Guides to identify community-based organizations to support the member in meeting their goals
• Collaborate with members, providers, and caregivers to ensure a positive outcome
• Explain complicated medical terms in plain language
• Educate members on appropriate care and settings based upon their healthcare needs
• Support members in understanding diagnostic tests and treatments, including costs, risks, and alternatives so they can make an informed decisions
• Prepare members for their inpatient and outpatient treatments and coordinate post-treatment care
• Support and coach members to improve management of their chronic conditions, including medication adherence and compliance

The Company

Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.