Utilization Management Clinician

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⚔️ Virginia – Remote

⚔️ Virginia – 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 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