Job Details

We are seeking an experienced and strategic Senior Clinical Consultant with deep experience in Utilization Management (UM) for Intellectual and Developmental Disabilities (IDD), Behavioral Health (BH), and Home and Community-Based Services (HCBS). This role involves partnering with healthcare organizations to assess, design, implement, and optimize clinical processes, systems, and programs. The ideal candidate has hands-on experience in community-based care models, understands person-centered planning, and is passionate about improving care outcomes for vulnerable and underserved populations and a proven track record in clinical consulting or health systems improvement.  The ideal candidate combines strong clinical expertise with operational insight into Medicaid-funded community-based services.

Essential Functions/Key Responsibilities:

• Collaborate with clients to assess current clinical workflows, quality initiatives, and care delivery models for BH, IDD & HCBS populations.
• Lead strategic consulting engagements focused on transforming UM functions across IDD, BH, and HCBS systems.
• Conduct needs assessments and gap analyses of clinical service models across residential, day, and community-based settings.
• Design and implement strategies to improve clinical outcomes, patient safety, and operational efficiency.
• Analyze current UM processes, clinical review workflows, and decision-making frameworks to identify inefficiencies and areas for improvement.
• Design person-centered outcomes-based UM models that align with Medicaid regulations, waiver authorities, and the HCBS Final Rule.
• Develop clinical criteria and review protocols tailored to community-based and residential services for complex populations.
• Support the implementation of electronic utilization management systems and ensure integration with case management and care coordination functions.
• Create training documents for UM clinicians and reviewers on evidence-based review standards, level of care criteria and documentation best practices.
• Evaluate UM performance data, identify trends (e.g., over/under-utilization), and recommend corrective actions to support quality and cost-effectiveness.
• Collaborate with compliance and policy teams to ensure adherence to federal and state regulatory requirements.
• Contribute clinical insight to RFP responses, program evaluations, and strategic planning for clients in the public and private sectors.
• Analyze clinical data to identify trends, opportunities, and areas for performance improvement.
• Lead clinical workstreams for projects related to waivers and integrated care delivery.
• Serve as a subject matter expert (SME) in clinical best practices, regulatory compliance, and care standards.
• Provide subject matter expertise on person-centered planning, functional assessments, behavior support plans, and trauma-informed care.
• Lead clinical workstreams in projects involving EHR optimization, population health, or care transformation.
• Translate clinical, regulatory, and policy requirements into actionable implementation plans for systems and provider organizations.
• Train and coach provider staff, care coordinators, and system leaders on clinical best practices, evidence-based interventions, and service planning.
• Collaborate with cross-functional teams (e.g., policy, data, operations) to support transformation initiatives and ensure compliance with federal and state guidelines.
• Contribute to business development efforts by supporting proposal writing, client presentations, and strategic planning.

Competencies:

• Excellent written and verbal communication skills with strong attention to detail. 
• Strong analytical, facilitation, and project leadership skills.
• Highly organized and proactive, with the ability to manage multiple priorities at once. 
• Proficient in Microsoft office suite.
• Ability to thrive in a fast-paced, evolving healthcare environment.
• Demonstrated ability to lead multi-stakeholder engagements and manage complex clinical transformation projects.
• Excellent communication, facilitation, and relationship-building skills with both provider-level and executive stakeholders.

Travel: 

• Remote with periodic travel as required (estimate <10%).

Required education and experience:

• Licensed clinician with an advanced degree in Nursing, Social Work, Psychology, Behavioral Health, or related field (e.g., RN, LCSW, LPC, PhD, PsyD, BCBA).
• 5-10+ years of clinical experience in IDD, BH, or HCBS, with at least 3 years in Utilization Management, clinical review, or prior authorization.
• 3+ years in consulting, leadership, or system transformation role.
• Deep understanding of Medicaid UM operations, medical necessity criteria, and CMS requirements for home- and community-based care.
• Proven experience working with or advising state Medicaid agencies, MCOs, or UM vendors on service authorization and care planning.
• In-depth knowledge of Medicaid policy, HCBS waivers, person-centered practices, and behavioral health integration.
• Familiarity with regulatory frameworks including HCBS Final Rule, Olmstead compliance, EVV, and value-based care initiatives.

Preferred education, certifications and/or experience:

• Experience working with state Medicaid agencies, managed care organizations, or national consulting firms in the IDD/BH/HCBS space.
• Experience implementing clinical quality frameworks such as CQL, HEDIS, or NCI indicators.
• Knowledge of behavioral support, crisis response, or dual-diagnosis populations (IDD + BH).
• Experience with data-informed decision-making and performance improvement strategies.
• Certification in Project Management (PMP), CPHQ, or Lean Six Sigma is a plus.

Physical Requirements/Work environment: 

• Must have a home office, mobile phone, and computer with security requirements met.
• Prolonged periods of sitting at a desk and working on a computer.
• Ability to speak, hear, and comprehend both written and verbal communications.

Other duties:

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and/or activities may change at any time with or without advanced notice.