Utilization Management Clinician

Job not on LinkedIn

🔥 3 minutes ago

🦬 Montana – Remote

🦬 Montana – Remote

💵 $71k - $106.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

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 Health Plans

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1933

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

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 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 outcomes • 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 that may become legal records • Perform concurrent review 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 behavioral health, home health, hospice, rehabilitation, residential, and outpatient services • 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 plan questions and healthcare navigation • Provide medical or contract interpretation support to PacificSource personnel, 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 • Support other Health Services Department staff and functions as needed • 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 PacificSource privacy policy and HIPAA confidentiality and security requirements • Travel approximately 5% of the time • 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 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 lift and carry files and business materials

🏖️ Benefits

• Equal opportunity employment • Work inside in a general office setting with ergonomically configured equipment • Employment remains AT-WILL at all times