Utilization Management Clinician – Tuesday, Saturday

Job not on LinkedIn

🔥 1 hour ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $71k - $106.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

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 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 review of members in inpatient, residential treatment, and partial hospitalization settings • Maintain contact with inpatient utilization review personnel regarding continued stay and level of care • Identify cases requiring discharge planning and coordinate transitions to post-acute, behavioral health, home health, hospice, 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 • Support multidisciplinary work on network-not-available, out-of-network exceptions, and one-time agreements • Serve as a primary resource for members and families navigating health plan and health system issues • Provide internal medical or contract interpretation support to 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 guidelines and procedures • Back up 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 confidentiality and security requirements • Perform other duties as assigned

🎯 Requirements

• Minimum of three years of nursing or behavioral health experience with varied medical and/or behavioral health exposure • Acute care and case management experience strongly preferred, including rehabilitation, home health, behavioral health, and hospice cases • Insurance industry experience helpful but not required • Active, unrestricted RN license, 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 • Ability to establish and maintain relationships with community services and providers • Maintains 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 read and comprehend written and spoken English • Ability to communicate clearly and effectively • Ability to stoop and bend, sit and/or stand for extended periods, perform repetitive typing/sorting/filing, and lift and carry files and business materials • Approximately 5% travel required

🏖️ Benefits

• Flexible telecommute policy • Medical, vision, and dental insurance • Incentive program • Paid time off and holidays • 401(k) plan • Volunteer opportunities • Tuition reimbursement and training • Life insurance • Flexible spending account options • Opportunities for personal growth and advancement • Opportunities for learning development and career advancement • Work-life balance • Competitive wages and outstanding benefits • Training, individual development, and career advancement opportunities