Clinical Services Utilization Supervisor

Case Manager – Hamilton & Surrounding Counties

Company: CareStar, Inc.
Location: Hamilton County, 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 field and 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 Social Worker (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

Apply Today

Ready to make a difference? Visit https://www.carestar.com/about-carestar/careers/ to apply and learn more about joining our team.