Utilization Management Clinician – Tuesday - Saturday

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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 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 promote 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, residential treatment, and partial hospitalization admissions • Maintain contact with inpatient facility utilization review personnel regarding continued stay and level of care • Identify cases requiring discharge planning and coordinate transitions to skilled nursing, rehabilitation, residential, outpatient, behavioral health, home health, and hospice services • Review referral and preauthorization requests using evidence-based criteria • Identify and negotiate with vendors and non-contracted providers • Work with multidisciplinary teams on network-not-available, out-of-network exceptions, and one-time agreements • Serve as a resource to members and families regarding health plan questions and healthcare navigation • Answer medical or contract interpretation questions from internal 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 Department guidelines and procedures • Support other Health Services Department staff and functions • Serve on committees, teams, and task groups • Represent the Health Services Department internally and externally • Meet department and company performance and attendance expectations • Follow privacy policy 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 • Active, unrestricted RN, LPC, LMFT, LCSW, or PMHNP license/credential required • Case Manager Certification accredited by CCMC preferred • Thorough knowledge of medical and behavioral health processes, diagnoses, care modalities, ICD and CPT codes • Knowledge of 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 records security • Ability to establish and maintain relationships with community services and providers • Ability to maintain current clinical knowledge and certification • Ability to work independently with minimal supervision • Ability to function as part of a collaborative team • Approximately 5% travel required • Ability to read and comprehend written and spoken English • Clear and effective communication skills • Ability to stoop and bend, sit and/or stand for extended periods, perform repetitive typing/sorting/filing, and lift/carry files and business materials

🏖️ Benefits

• Work from home arrangement • Case Manager Certification support/preference as accredited by CCMC • Equal opportunity and diversity-focused work environment