IT - Consultant | Development process generic | SaaS ...

POC: Bharath Subramanya ATTENTION ALL SUPPLIERSREAD BEFORE SUBMITTING: • UPDATED CONTACT NUMBER and EMAIL ID is a MANDATORY REQUEST from our client for all the submissions • Limited to 2 submission per supplier. Please submit your best. • We prioritize endorsing those with complete and accurate information • Avoid submitting duplicate profiles. We will Reject/Disqualify immediately. • Make sure that candidate's interview schedules are updated. Please inform the candidate to keep their lines open. MANDATORY: Please include in the resume the candidate's complete & updated contact information (Phone number, Email address and Skype ID) as well as a set of 5 interview timeslots over a 72-hour period after submitting the profile when the hiring managers could potentially reach to them. PROFILES WITHOUT THE REQUIRED DETAILS and TIME SLOTS will be REJECTED. Job title: Consultant Work Location: Hartford, CT Vendor Rate: market rate USD per hour Minimum years of experience: 8+ Would you require the candidates to meet you for in person interview? No Is Skype/WebEx interview,OK? OK Is this onsite/remote position: Onsite If onsite, will you be considering relocation candidates: Yes Does this position require Visa independent candidates only? Yes Job Description: The Clinical Lead oversees day-to-day operations of utilization management, clinical reviews, service authorization processes, and care management functions for the health plan. This role provides clinical expertise, ensures regulatory compliance, supports staff development, and drives appropriate, high-quality care across the continuum. Must Have Skills Experience with Medicare Advantage, Medicaid Managed Care, or Commercial health plans. Experience in provider relations, audit support, or process improvement initiatives. Familiarity with UM and CM platforms Minimum years of experience 8-10 years Top 3 responsibilities you would expect the Subcon to shoulder and execute Conduct and oversee utilization reviews (prospective, concurrent, and retrospective) using evidence based criteria such as InterQual, MCG, CMS, and state guidelines. Perform clinical reviews of inpatient, outpatient, specialty, and ancillary services to determine medical necessity, level of care, and appropriateness. Ensure UM decision making complies with federal/state regulations, CMS requirements, NCQA/URAC standards, and timeliness expectations. Nice to have skills Support escalation and collaboration with Medical Directors for cases requiring physician review or adverse determinations. Provide coaching to staff on documentation quality, criteria selection, and clinical justification.

Created: 2026-03-11