Utilization Management Clinician – Tuesday - Saturday

Job not on LinkedIn

🕒 3 days ago

🌲 North Carolina – Remote

🌲 North Carolina – Remote

💵 $71k - $106.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

✨ Clinician

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PacificSource Health Plans

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1933

⚕️ Healthcare Insurance

💸 Finance

🧘 Wellness

Healthcare Insurance • Finance • Wellness

PacificSource Health Plans is a healthcare provider that offers a range of health insurance solutions, including plans for individuals, families, and employers. Their offerings include Medicare and Medicaid plans, dental coverage, and administrative services for small and large groups. Committed to member care, PacificSource emphasizes customer service and provides various resources for health management, including mental health support and wellness programs.

📋 Description

• Collaborate closely with physicians, nurses, social workers, and a wide range of medical and non-medical professionals to coordinate delivery of healthcare services • Assess the member’s specific health plan benefits and the additional medical, community, or financial resources available • Provide utilization management (UM) services which promote quality, cost-effective outcomes by helping member populations achieve effective utilization of healthcare services • Facilitate outstanding member care using fiscally responsible strategies • Collect and assess member information pertinent to member’s history, condition, and functional abilities in order to promote wellness, appropriate utilization, and cost-effective care and services • Coordinate necessary resources to achieve member outcome goals and objectives • Accurately document case notes and letters of explanation which may become part of legal records • Perform concurrent review of members admitted to inpatient facilities, residential treatment centers, and partial hospitalization programs • Maintain contact with the inpatient facility utilization review personnel to assure appropriateness of continued stay and level of care • Identify cases that require discharge planning, including transfer to skilled nursing facilities, rehabilitation centers, residential, and outpatient to include behavioral health, home health, and hospice services while considering member co-morbid conditions • Review referral and preauthorization requests for appropriateness of care within established evidence-based criteria sets • When applicable, identify and negotiate with appropriate vendors to provide services • When appropriate, negotiate discounts with non-contracted providers and/or refer such providers to Provider Network Department for contract development • Work with multidisciplinary teams utilizing an integrated team-based approach to best support members

🎯 Requirements

• Minimum of three (3) years of nursing or behavioral health experience • Active, unrestricted Registered Nurse (RN) license, Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), Licensed Clinical Social Worker (LCSW), or Psychiatric Mental Health Nurse Practitioner (PMHNP) credential required • Case Manager Certification as accredited by CCMC preferred • Thorough knowledge and understanding of medical and behavioral health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes • Understanding of contractual benefits and options available outside contractual benefits • Working knowledge of community services, providers, vendors and facilities available to assist members • Understanding of appropriate case management plans • Ability to use computerized systems for data recording and retrieval • Assures patient confidentiality, privacy, and health records security • Establishes and maintains relationships with community services and providers • Maintains current clinical knowledge base and certification • Ability to work independently with minimal supervision

🏖️ Benefits

• Flexible telecommute policy • Medical, vision, and dental insurance • Incentive program • Paid time off and holidays • 401(k) plan • Volunteer opportunities • Tuition reimbursement and training • Life insurance • Options such as a flexible spending account