Utilization Management Clinician
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Job Description
Utilization Management Clinician coordinating member care and authorizations for PacificSource, a health insurance provider. Reviewing medical necessity, discharge planning, provider resources, and cost-effective treatment across care settings.
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 and 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
- Perform concurrent reviews for 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 skilled nursing services
- Review referral and preauthorization requests using evidence-based criteria
- Identify and negotiate with vendors and non-contracted providers
- Support multidisciplinary teams on 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 with Health Services guidelines and procedures
- Provide backup support, serve on committees and task groups, and represent the Health Services Department
- Meet performance and attendance expectations and comply with privacy and HIPAA requirements
- Perform other duties as assigned
Requirements:
- Minimum 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
- Current clinical knowledge base and certification
- Ability to work independently with minimal supervision and as part of a collaborative team
- Ability to meet performance and attendance expectations
- Ability to read and comprehend written and spoken English
- Clear and effective written and verbal communication
- Physical ability to stoop, bend, sit or stand for extended periods, perform repetitive typing/sorting/filing motions, and lightly lift and carry files and business materials
Benefits:
- Work from home arrangement
- Equal opportunity workplace
- Diverse and inclusive work environment
- Ergonomically configured equipment
- Professional development through maintaining current clinical knowledge base and certification
- Approximately 5% travel
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