Utilization Management Clinician

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🐊 Florida – Remote

🐊 Florida – Remote

💵 $71k - $106.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 20%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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PACIFICSOURCE

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1933

Not-for-profit health plans

📋 Description

• Collaborate with physicians, nurses, social workers, and medical and non-medical professionals to coordinate healthcare services • Assess member 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 regarding history, condition, and functional abilities • Coordinate resources to achieve member outcome goals and objectives • Document case notes and letters of explanation that may become legal records • Perform concurrent review for members in inpatient facilities, residential treatment centers, and partial hospitalization programs • Maintain contact with inpatient facility utilization review personnel to assess continued stay and level of care • Identify cases requiring discharge planning, including transfers to skilled nursing, rehabilitation, residential, outpatient, behavioral health, home health, and hospice services • Review referral and preauthorization requests using evidence-based criteria sets • Identify and negotiate with appropriate vendors when applicable • Negotiate discounts with non-contracted providers and refer providers for contract development when appropriate • Work with multidisciplinary teams on network-not-available, out-of-network exceptions, and one-time agreements • Serve as primary resource for members and families regarding health plan questions and healthcare-system navigation • Interact with PacificSource personnel to ensure quality customer service • Answer medical or contract interpretation questions referred by other departments, physicians, and providers • Assist employers and agents with healthcare resource and procedure questions • Identify high-cost utilization and refer cases to Large Case Reinsurance RN and Care Management teams • Assist the Medical Director in developing Health Services Department guidelines and procedures • Provide backup and resources for Health Services Department staff and functions • Serve on designated committees, teams, and task groups • Represent the Health Services Department internally and externally as requested by the Medical Director • Meet department and company performance and attendance expectations • Follow PacificSource privacy policy and HIPAA laws and regulations • Perform other duties as assigned

🎯 Requirements

• Minimum of three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required • Experience in acute care, case management, including cases that require rehabilitation, home health, behavioral health and hospice treatment strongly preferred • Insurance industry experience helpful, but not required • 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, health insurance and state-mandated benefits • 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 • Ability to maintain patient confidentiality, privacy, and health records 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 • Ability to function as part of a collaborative, cohesive community • Ability to read and comprehend both written and spoken English • Ability to communicate clearly and effectively • Ability to stoop and bend, sit and/or stand for extended periods, perform repetitive motions, and light lifting/carrying • Travel approximately 5% of the time