Utilization Management Clinician

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

📋 Description

• Collaborate with physicians, nurses, social workers, and a variety of medical and non-medical professionals to facilitate healthcare delivery.

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

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

• Gather and assess member information regarding their history, conditions, and functional abilities.

• Coordinate resources to meet member outcome goals and objectives.

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

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

• Maintain communication with inpatient facility utilization review staff regarding continued stays and levels of care.

• Identify cases that necessitate discharge planning and coordinate transfers and services, including behavioral health, home health, and hospice care.

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

• Identify and negotiate with vendors when necessary.

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

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

• Act as the primary resource for members and families regarding health plans and navigation within the healthcare system.

• Interact with PacificSource personnel to ensure high-quality customer service.

• Address medical or contract interpretation inquiries from other departments, physicians, and providers.

• Assist employers and agents with questions regarding healthcare resources and procedures.

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

• Assist the Medical Director in formulating guidelines and procedures for the Health Services Department.

• Provide backup and resources for Health Services Department staff and functions.

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

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

• Perform additional duties as assigned.

⛳️ Requirements

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

• Experience in acute care, case management, including rehabilitation, home health, behavioral health, and hospice treatment is strongly preferred.

• Experience in the insurance industry is advantageous but not mandatory.

• 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 and understanding of medical and behavioral health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance, and state-mandated benefits.

• Familiarity with contractual benefits and options available beyond contractual benefits.

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

• Understanding of appropriate case management plans.

• Ability to utilize computerized systems for data recording and retrieval.

• Ability to work independently with minimal supervision.

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

• Must meet department and company performance and attendance expectations.

• Must adhere to PacificSource privacy policies and HIPAA laws and regulations concerning the confidentiality and security of protected health information.

• Ability to read and understand both written and spoken English.

• Communicate clearly and effectively.

• Ability to stoop, 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.

• At-will employment.

• Ergonomically designed equipment.

• Approximately 5% travel.