Clinical Care Manager- Utilization Review

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients.

We are seeking a Clinical Care Manager who is passionate about advancing high‑quality, compliant, patient‑centered care through precise and timely Utilization Review. In this role, you will apply clinical expertise and regulatory knowledge to evaluate healthcare services, ensure medically necessary care, support provider decision-making, and promote effective care coordination. This is a detailed, analytical, and highly collaborative role that directly contributes to the integrity of care management operations and the member experience.

Utilization Review & Clinical Determinations: Complete timely review of healthcare services using appropriate medical criteria to support determinations. Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards, and Guidehealth policies. Communicate precertification and concurrent review decisions—verbally and in writing—to required parties within defined timeframes. Clinical Consultation & Collaboration: Partner with the Medical Director and Peer Reviewers for cases requiring medical necessity evaluation, treatment appropriateness, or quality‑of‑care review. Communicate routinely with ordering providers, provider organizations, and when appropriate, members or their representatives. Care Coordination & Member Support: Identify and refer eligible members to disease management programs to enhance care quality and continuity. Manage and document on‑call phone communications with members and providers on a rotational basis. Compliance, Quality & Documentation: Maintain confidentiality of all member information and case records. Participate in quality management initiatives and support related documentation, reporting, data collection, and committee activities. Prepare benefit exhaustion letters upon request. Assist with the design and maintenance of clinical and/or client-specific reports, spreadsheets, and analyses. Maintain current knowledge of relevant regulations, multi‑jurisdictional requirements, medical group guidelines, and URAC standards. Professional Development: Maintain ongoing professional education and growth aligned with Illinois nursing regulations and contemporary clinical practice.