Utilization Management Clinician – Tuesday to Saturday

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🔥 6 minutes ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $71k - $106.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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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, including documentation that may become part of legal records • Perform concurrent reviews of members in inpatient facilities, residential treatment centers, and partial hospitalization programs • Maintain contact with inpatient facility utilization review personnel regarding continued stay and level of care • Identify cases requiring discharge planning and coordinate transfers and services across skilled nursing, rehabilitation, residential, outpatient, behavioral health, home health, and hospice settings • Review referral and preauthorization requests using evidence-based criteria • Identify and negotiate with 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 a primary resource for members and families regarding health plans and healthcare system navigation • 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 • Back up and support other Health Services Department 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 policies and HIPAA confidentiality and security requirements • Perform other duties as assigned

🎯 Requirements

• Minimum three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure • Experience in acute care and case management strongly preferred, including rehabilitation, home health, behavioral health, and hospice cases • 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 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 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 meet performance and attendance expectations • 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 • Ability to read and comprehend written and spoken English • Ability to communicate clearly and effectively • Approximately 5% travel required

🏖️ Benefits

• Work from home (WFH) • Equal opportunity employment • Ergonomically configured equipment • Company values and culture focused on customer service, communication, community improvement, social justice, equity, diversity and inclusion, creativity, innovation, and excellence