Utilization Management Clinician

This is a fully remote position, open to applicants in Florida.

📋 Description

• Collaborate with physicians, nurses, social workers, and both medical and non-medical professionals to coordinate healthcare services.

• Evaluate members’ health plan benefits along with available medical, community, and financial resources.

• Deliver utilization management services that promote quality and cost-effective healthcare utilization.

• Gather and analyze member information concerning their history, condition, and functional abilities.

• Coordinate resources to meet the outcome goals of members.

• Document case notes and explanatory letters that may serve as legal records.

• Conduct concurrent reviews for members in inpatient facilities, residential treatment centers, and partial hospitalization programs.

• Maintain communication with inpatient facility utilization review personnel regarding continued stay and level of care.

• Identify cases that necessitate discharge planning and coordinate transfers and services, including skilled nursing, rehabilitation, residential, outpatient, behavioral health, home health, and hospice care.

• Review referral and preauthorization requests based on evidence-based criteria.

• Identify and negotiate with suitable vendors.

• Negotiate discounts with non-contracted providers or refer them for contract development.

• Collaborate with multidisciplinary teams on network-not-available, out-of-network exceptions, and one-time agreements.

• Act as a primary resource for members and families regarding health plan inquiries and healthcare navigation.

• Provide customer service and internal medical or contract interpretation support.

• Assist employers and agents with questions related to healthcare resources and procedures.

• Identify high-cost utilization and refer cases to reinsurance and care management teams.

• Support the Medical Director in developing guidelines and procedures for the Health Services Department.

• Offer backup support to Health Services Department staff and functions.

• Participate in designated committees, teams, and task groups.

• Represent the Health Services Department both internally and externally as requested.

• Meet the performance and attendance expectations of the department and company.

• Adhere to PacificSource privacy policy and HIPAA confidentiality and security requirements.

• Perform other duties as assigned.

• Work primarily in a general office environment, with travel required approximately 5% of the time.

⛳️ Requirements

• A minimum of three (3) years of nursing or behavioral health experience with diverse medical and/or behavioral health exposure and capability.

• An 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 is required.

• Case Manager Certification accredited by CCMC is preferred.

• Comprehensive knowledge 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 beyond contractual benefits.

• Working knowledge of community services, providers, vendors, and facilities.

• Familiarity with appropriate case management plans.

• Proficiency in using computerized systems for data recording and retrieval.

• Ability to maintain patient confidentiality, privacy, and the security of health records.

• Current clinical knowledge base and certification.

• Capability to work independently with minimal supervision.

• Ability to function as part of a collaborative, cohesive community.

• Proficient in reading and comprehending written and spoken English.

• Strong communication skills to convey information clearly and effectively.

• Capacity to stoop and bend, sit and/or stand for extended periods, perform repetitive typing/sorting/filing motions, and lift/carry files and business materials.

🏝️ Benefits

• Equal opportunity employment.

• Work-from-home arrangement.

• Ergonomically configured equipment.

• Opportunities for professional development through maintaining current clinical knowledge base and certification.

• Participation in committees, teams, and task groups.

• At-will employment.