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Date Posted: 12/20/2017

Job Snapshot

  • Employee Type:
  • Location:
    Bangor, ME
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:

Job Description




REPORTS TO:      Clinical Supervisor

DEPARTMENT:  Review Operations Department

FLSA STATUS:     (X) Exempt                          ( ) Nonexempt

Summary Description

Within the scope of service, provides site visits or telephonic outreach; behavioral health, disease and/or case management, education and support to plan members, providers or client by assessing, planning, implementing, monitoring and/or evaluating options and services to ensure appropriate, care/services are being provided to members.


  • Conducts member and/or provider assessments, audits, training and consultation to assure plans and interventions are appropriate.  As appropriate, monitors and evaluates the services and community based resources necessary to respond to the individual member’s health needs. 
  • Uses independent judgment, clinical knowledge/competence, communication skills, and problem solving and conflict resolution to ensure optimal member, provider and client outcomes with consideration to payer requirements. 
  • Ensures day-to-day processes are conducted in accordance with regulatory standards.
  • Seeks consultation from physicians, clinical and other disciplines and departments as required to ensure appropriate care is being rendered.
  • Ongoing reassessment of processes to offer opportunity for improvement and/or change. 
  • Foster positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building in order to facilitate the review process.
  • Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review.
  • Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, adherence to HIPAA polices. 
  • Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following KEPRO policies, procedures and guidelines
  • Cross-trains to perform duties of other contracts within the KEPRO network to provide a flexible workforce to meet client/consumer needs.

The list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary from time to time.


  • Education (general level if required) or specific courses         
  • Active unrestricted RN, Social Worker, Counselors or other applicable State and/or Compact State clinical license and/or certifications.
  • Associate’s Degree or Bachelor’s Degree Program
  • Social Workers must have an unrestricted independent licensure.
  • Knowledge, Skills, Abilities (KSA)
  • Knowledge of the organization of medical records, medical terminology, and disease process required.
  • Strong clinical/social assessment and critical thinking skills required.
  • Excellent verbal and written communication skills required.
  • Ability to use independent judgment and discretion to address, resolve and process problems impeding the service needs.
  • Proactively identify and resolves delays and obstacles.
  • Ability to work in a team environment. 
  • Flexibility and strong organizational skills needed. 
  • Must be proficient in MS Office, Internet/Web Navigation
  • Must have high-speed (no dial-up) internet at home.
  • Must be willing to travel and have active, unrestricted license, reliable transportation and active auto insurance.
  • Must have an OSHA complaint home workspace committed to confidentiality of PHI.
  • Knowledge of NCQA/URAC standards preferred.


  • Minimum of one year UR and/or Prior Authorization, QA, Case Management or related experience.
  • Basic computer skills (copy/cut, paste, maneuvering screens and typing) necessary.
  • For BH Programs:  Minimum 2 years direct behavioral/mental health experience in a clinical setting.

Mental and Physical Requirements        

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations will be made as required by law in an attempt to enable an individual with a disability to perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time; key and/or control objects; interact extensively with internal and external customers; occasionally lift and/or move objects weighing up to 10 pounds; and occasionally travel within the state.

EOE AA M/F/Vet/Disability


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