Clinical Services Utilization Supervisor

Case Manager – Hamilton & Surrounding Counties Company: CareStar, Inc. Location: HamiltonCounty, Ohio (and surrounding areas) Job Type: Full Time | Remote with Field Visits Industry: Healthcare / Social Services / Case Management About the Opportunity at CareStar Founded in 1988 in Cincinnati, Ohio, CareStar, Inc. is a recognized leader in long-term care case management and population health. With a mission to Improve Communities by Improving Lives, we proudly serve individuals across Ohio through compassionate, high-quality care coordination. We are currently seeking Clinical Services Utilization Supervisor to join our Ohio Home Care program. This is a meaningful opportunity for professionals who are passionate about helping others live healthier, more independent lives. As a Clinical Services Utilization Supervisor , you’ll work directly with individuals to assess their needs, develop personalized care plans, and connect them with essential services and supports. You’ll be part of a mission-driven team that values your expertise, supports your growth, and empowers you to make a real difference in your community. Key Responsibilities Monitor service delivery and ensure compliance with program guidelines Serve as the lead advocate and care coordinator for each participant Educates, guides, oversees, and counsel’s clinical employees in the performance of task related to Due Process and Prior Authorizations. Formulates training material for Due Process and Prior Authorizations and conducts training for Clinical Team as necessary. Provides guidance to staff related to applicable rule reference and disenrollment determinations; identifies problematic cases and refers to the Clinical Supervisor and/or Clinical Manager as appropriate. Maintains/updates knowledge of Medicare, Medicaid, insurance and program and State specific waivers; maintains knowledge of the Americans with Disabilities Act. Understands current and future state and other program information to assist with business objectives; establishes rapport with State and other programs employees. Prepares appeal summaries and exhibits list for processing to be presented at hearing; represents CareStar at appeal hearings; be available to provide testimony at appeal hearings. Reviews hearing rights for appropriateness and submits them for processing to ensure compliance with the State administrative code. Reviews hearing decisions and coordinates compliance with the determination, prepares and submits compliance forms per requirements, including issuance of hearing rights. Provides support to staff in assessing need for prior authorization and assures that determination is supported by medical necessity; reviews prior authorizations prior to submissions to state specific Department of Medicaid for completeness and compliance with the state specific administrative code and CareStar requirements. Adhere to the CareStar Rule in performance of job responsibilities. Understand and comply with CareStar Policies and Procedures. Maintain confidentiality as related to patient information. Any disclosures of confidential information made unlawfully outside the proper course of duty will be treated as a serious disciplinary offense. Follow the Acceptable Use Policy while using any information systems owned or controlled by CareStar, Inc. Minimum Qualifications Bachelor’s degree in Social Work, Counseling, Psychology, Nursing, or a related fieldand at least three (3) years of either pediatric, Developmental Disabilities or mental health experience within the last ten (10) years is desirable. Licensed Social Worker (LSW), Licensed Independent SocialWorker (LISW)or Registered Nurse (RN) Minimum 3 year of experience in home and community-based services (within the last 10 years) Experience working with individuals with chronic conditions or severe and persistent mental illness Strong knowledge of Medicaid, behavioral health systems, and local community resources Why Join CareStar? Remote flexibility with meaningful community engagement Competitive salary based on experience and education Comprehensive benefits: Medical, dental, vision, life insurance 401(k) with a generous company match Paid time off + 10 paid holidays Employee Stock Ownership Plan (ESOP) – become a part-owner in the company Supportive, mission-driven culture focused on improving lives #J-18808-Ljbffr CareStar, Inc.