Remote Utilization Review Rn Jobs in Portland, ME

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.
Position Summary
The Clinical Program Manager - Case Management leads strategic initiatives for the Generations Advantage and USFHP lines of business. In this role, you will design, implement, and oversee targeted programs aimed at improving care transitions, reducing avoidable readmissions, and enhancing post-discharge follow-up, while ensuring strict compliance with regulatory requirements. Additionally, you will champion our integrated, whole-person care model by optimizing workflows and operational reporting. Acting as a key resource across the organization, you will collaborate with cross-functional stakeholders to align clinical strategies with operational excellence and ongoing program success.
Job Description
PRIMARY DUTIES AND RESPONSIBILITIES

• Supports program development activities, including operational reporting and program resources
• Translates organizational strategy into actionable, localized case management work plans
• Streamlines case management workflows to eliminate clinical inefficiencies and improve member engagement
• Optimizes data reporting structures to track program metrics, identifying trends that require clinical interventions
• Monitors program benchmarks and key performance indicators (KPIs) to measure the success of CM Program
• Ensures all clinical initiatives comply with TriCare, CMS, NCQA, and other state or federal regulatory standards
• Identifies trends, gaps and operational risks through performance monitoring
• Develops presentations, communication, and program tools in support of CM Program
• Partners with cross-functional leaders to align care model and implement new program initiatives
• Facilitates committees and working groups to communicate program updates, barriers, and financial outcomes
• Collaborates with IT and analytics teams to refine case management software platforms and reporting dashboards and scorecards.

Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.
POSITION QUALIFICATIONS
Education:

• Bachelor's Degree in Health Science, Nursing or related field required.
• Master's degree in Business Administration (MBA), Healthcare Administration (MHA), or Public Health (MPH) preferred.

Licensure/certification:

• Certified Case Manager (CCM) or American Case Management Association (ACMA) certification preferred.

Experience:

• 10 years' experience in healthcare including managed care, with a focus in Program Management, overseeing clinical programs and driving process improvement initiatives required.
• Experience using data and data analysis to design and monitor programs and manage success, including ROI, of programs required.
• Experience in evaluating financial and clinical performance metrics required.
• Experience in Medicare Advantage and TRICARE preferred.

Knowledge:

• Demonstrated experience with NCQA case management accreditation standards, audit preparations, and HEDIS quality metrics required.
• Proficiency in health IT systems, including specialized Case Management platforms (e.g., TruCare, Salesforce Health Cloud,), Electronic Health Records (EHRs), and clinical data analytics reporting tools preferred.

Skills:

• Excellent communication and presentation skills, oral and written.
• Strong organizational skills including the ability to work independently and prioritize work.
• Competence with computers and business applications; Microsoft Excel, Visio, Word, PowerPoint, Outlook, Access.

Abilities:

• Demonstrated track record of driving new clinical programs through implementation and
• monitoring.
• Demonstrated expertise managing teams and multi-disciplinary workgroups in achieving team objectives, without direct authority.
• Strong attention to detail and the ability to multitask.
• Ability to review, interpret and present information to Health Plan Leadership and external partners.
• Ability to lead change and assist in the development of change strategies in support of Health Plan and Organizational goals and objectives.

Pay Range:$114,957.40 - $142,006.20The pay range above reflects the anticipated base pay range based on a full-time position. Actual compensation will be determined based on factors such as experience, skills, qualifications, and other job-related considerations. Employees may also be eligible for additional compensation, including incentive or commission-based programs, where applicable and subject to the terms of the relevant plan.In addition to base compensation, we offer a comprehensive benefits package including medical, dental, vision, retirement savings with employer contributions, paid time off (including volunteer time off!), pie day, and other employee benefits.
This position is not eligible for immigration sponsorship.
We are an equal opportunity/affirmative action employer.
Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact jobinquiries@martinspoint.org
Do you have a question about careers at Martin's Point Health Care? Contact us at: jobinquiries@martinspoint.org