Concierge Care Management Specialist

Concierge Care Management Specialist

The Concierge Care Management Specialist effectively reviews VIP member medical requests and determines the correct medical specialty for clinical referrals to maintain optimal level of access to services according to established requirements and timelines. This role acts as a clinical resource for the Concierge Service, providing accurate specialist recommendations based on the member's symptoms and medical history. Additionally, this position reviews clinical documentation and collaborates with internal clinical teams to ensure accurate and efficient care routing.

Essential Functions:

• Review incoming VIP service requests and medical documentation to identify, verify, and confirm the exact medical specialty required for the member's clinical condition.
• Evaluate clinical notes, member histories, and medical records to ensure all clinical information is complete, accurate, and sufficient before a specialty referral is finalized.
• Serve as the primary clinical resource for non-clinical Concierge personnel, clarifying complex diagnoses, terminology, and specialist criteria to assist them in fulfilling their work plans.
• Provide administrative and outreach support by contacting insureds, providers, and contracted facilities to obtain missing clinical data necessary for case evaluation.
• Ensure member care aligns with established company service levels, applying professional clinical judgment to assess and validate medical necessity throughout the referral process.
• Coordinate with the internal network management team to align recommended specialties with available network providers, and support the Supervisor by tracking routing accuracy and processing times for operational reports.
• Participate in special clinical or operational projects assigned to the Concierge department as required by management to support business objectives.
• Responsible for establishing and retaining business relationships with VIP members, providers, healthcare facilities, and key business partners to ensure service excellence, client satisfaction, and retention.
• Coordinate and support the resolution of complex service requests, ensuring timely follow-up and communication with members, providers, and internal stakeholders.
• Collaborate with internal departments and external partners to facilitate service coordination and address customer needs effectively.

Additional Functions:

• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

Minimum Qualifications:

Education and Experience: Bachelor's degree in Nursing Sciences. At least three (3) years of clinical nursing experience, with a preference for a background in triage, utilization review, or care coordination.

Proven experience may be replaced by previously established requirements.

Certifications / Licenses: A valid License and Registration of Nurse & Association Nursing Professionals of Puerto Rico are required.

Other: N/A

Languages:

• Spanish Advanced (comprehensive, writing and verbal)
• English Advanced (comprehensive, writing and verbal)

We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.