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 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 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 support wellness, appropriate utilization, and cost-effective care • Coordinate resources to achieve member outcome goals • Document case notes and letters of explanation, including records that may become legal records • Perform concurrent reviews for members in 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 outpatient services • Review referral and preauthorization requests using evidence-based criteria • Identify and negotiate with vendors and negotiate discounts with non-contracted providers • 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 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 in developing Health Services Department guidelines and procedures • Provide backup and resources for Health Services 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 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 • 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 • 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 and as part of a collaborative team • 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, and filing, and lightly lift and carry files and business materials • Approximately 5% travel required

🏖️ Benefits

• Flexible telecommute policy • Medical insurance • Vision insurance • Dental insurance • Incentive program • Paid time off • Paid 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 • Training, individual development, and career advancement opportunities