Clinical Case Specialist

At ScionHealth, we empower our caregivers to do what they do best. We value every voice by caring deeply for every patient and each other. We show courage by running toward the challenge and we lean into new ideas by embracing curiosity and question asking. Together, we create our culture by living our values in our day-to-day interactions with our patients and teammates.

Job Summary

• The Clinical Appropriate Management (CAM) Specialist is responsible for ensuring the delivery of safe, timely, and appropriate inpatient psychiatric care by coordinating utilization review, discharge planning, and documentation supporting medical necessity and regulatory compliance
• This position supports clinical admissions, collaborates across interdisciplinary teams, and engages patients and families to ensure care aligns with CMS Conditions of Participation, Joint Commission standards, and payer guidelines.

Essential Functions

• Conduct concurrent reviews using InterQual, MCG, and payer-specific criteria
• Submit clinical reviews, extension requests, and appeals to insurance plans
• Participate in interdisciplinary treatment team meetings to assess patient needs and discharge readiness
• Coordinate discharge plans per CMS CoPs §482.43 and Joint Commission standards
• Document discharge planning and patient/family involvement in EMR
• Liaise with internal and external stakeholders for smooth discharge transitions
• Assist Clinical Liaison and Program Director with referrals, marketing, and admissions
• Provide precertification details for new/pending admissions
• Maintain current knowledge through continuing education
• Collaborate with business office on Medicaid and financial planning needs
• Review documentation for consistency and regulatory alignment
• Monitor denials and lead appeal processes when warranted

Knowledge/Skills/Abilities/Expectations

• In-depth knowledge of CMS, Joint Commission, and payer discharge requirements
• Skilled in InterQual/MCG use for behavioral health and continued stay reviews
• Strong verbal/written communication and interpersonal collaboration skills
• Proficient in EMR systems and audit-compliant documentation
• Effective critical thinking, multitasking, and decision-making abilities
• Familiarity with Medicaid, transitional care, and community resources
• Ethical, patient-centered, and professional in all responsibilities
• Competent in Microsoft Office Suite and clinical information systems
• Must demonstrate good attendance and be available for travel as needed

Education

• Bachelor’s degree in Nursing, Social Work, or related field required
• Master’s preferred

Licenses/Certifications

• Current RN or LCSW licensure preferred
• Case Management Certification (ACM, CCM) or UR-specific certification preferred

Experience

• 3+ years’ experience in behavioral health, case management, or utilization review preferred