Utilization Management Clinician
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Job Description
Utilization management clinician coordinating member care for PacificSource, a not-for-profit health insurer. Reviewing authorizations, inpatient stays, discharge plans, and cost-effective healthcare resources.
Responsibilities:
- Collaborate with physicians, nurses, social workers, and medical and non-medical professionals to coordinate healthcare services
- Assess members’ health plan benefits and available medical, community, and financial resources
- Provide utilization management services promoting quality, cost-effective healthcare utilization
- Collect and assess member information to support wellness, appropriate utilization, and cost-effective care
- Coordinate resources to achieve member outcome goals
- Document case notes and letters of explanation, including records that may become legal records
- Perform concurrent reviews for members in inpatient facilities, residential treatment centers, and partial hospitalization programs
- Maintain contact with inpatient utilization review personnel regarding continued stay and level of care
- Identify cases requiring discharge planning and coordinate transfers and behavioral health, home health, hospice, rehabilitation, and outpatient services
- Review referral and preauthorization requests using evidence-based criteria
- Identify and negotiate with vendors and negotiate discounts with non-contracted providers
- Work with multidisciplinary teams on network-not-available, out-of-network exceptions, and one-time agreements
- Serve as a primary resource for members and families navigating health plan and healthcare-system issues
- Answer medical or contract interpretation questions from departments, physicians, and providers
- Assist employers and agents with healthcare resource and procedure questions
- Identify high-cost utilization and refer cases to reinsurance and care management teams
- Assist the Medical Director in developing Health Services Department guidelines and procedures
- Provide backup and resources for Health Services staff and functions
- Serve on designated committees, teams, and task groups
- Represent the Health Services Department internally and externally as requested
- Meet department and company performance and attendance expectations
- Follow privacy policy and HIPAA confidentiality and security requirements
- Perform other duties as assigned
Requirements:
- Minimum of three years of nursing or behavioral health experience with varied medical and/or behavioral health exposure
- Experience in acute care and case management strongly preferred
- Experience with rehabilitation, home health, behavioral health, and hospice treatment strongly preferred
- Insurance industry experience helpful but not required
- Active, unrestricted RN, LPC, LMFT, LCSW, or PMHNP credential required
- Case Manager Certification accredited by CCMC preferred
- Thorough knowledge of medical and behavioral health processes, diagnoses, care modalities, ICD and CPT procedure codes, health insurance, and state-mandated benefits
- Understanding of contractual benefits and options outside contractual benefits
- Working knowledge of community services, providers, vendors, and facilities
- Understanding of appropriate case management plans
- Ability to use computerized systems for data recording and retrieval
- Knowledge of patient confidentiality, privacy, and health-record security
- Ability to establish and maintain relationships with community services and providers
- Ability to maintain current clinical knowledge base and certification
- Ability to work independently with minimal supervision and as part of a collaborative team
- Ability to read and comprehend written and spoken English
- Ability to communicate clearly and effectively
- Ability to stoop and bend, sit and/or stand for extended periods, perform repetitive typing, sorting, and filing, and lightly lift and carry files and business materials
- Approximately 5% travel required
Benefits:
- Flexible telecommute policy
- Medical insurance
- Vision insurance
- Dental insurance
- Incentive program
- Paid time off
- Paid holidays
- 401(k) plan
- Volunteer opportunities
- Tuition reimbursement and training
- Life insurance
- Flexible spending account options
- Opportunities for personal growth and advancement
- Opportunities for learning development and career advancement
- Work-life balance
- Training, individual development, and career advancement opportunities
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