Utilization Management Clinician

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

📋 Description

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

• Evaluate member health plan benefits alongside available medical, community, and financial resources

• Deliver utilization management services that foster quality and cost-effective outcomes

• Gather and analyze member information to encourage wellness, appropriate utilization, and economical care

• Coordinate resources to accomplish member outcome 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 necessitating discharge planning and coordinate transfers along with behavioral health, home health, hospice, rehabilitation, residential, and outpatient services

• Review referral and preauthorization requests utilizing evidence-based criteria

• Identify and negotiate with vendors when necessary

• Negotiate discounts with non-contracted providers and refer providers for contract development as appropriate

• Collaborate with multidisciplinary teams on network unavailability, out-of-network exceptions, and one-time agreements

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

• Provide medical or contract interpretation support to PacificSource staff, physicians, and providers

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

• Identify high-cost utilization cases and refer them to Large Case Reinsurance RN and Care Management teams

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

• Assist other staff and functions within the Health Services Department as necessary

• Participate in assigned committees, teams, and task groups

• Represent the Health Services Department both internally and externally when requested

• Meet departmental and company performance and attendance standards

• Adhere to PacificSource privacy policy and HIPAA confidentiality and security mandates

• Travel approximately 5% of the time

• Execute other 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 skills required

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

• Familiarity with the insurance industry is beneficial 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, and procedure codes including ICD and CPT Codes, as well as health insurance and state-mandated benefits

• Familiarity with contractual benefits and options available beyond those benefits

• A working knowledge of community services, providers, vendors, and facilities that can assist members

• Understanding of appropriate case management plans

• Proficiency in using computerized systems for data entry and retrieval

• Ability to work independently with minimal oversight

• Capability to function as part of a collaborative and cohesive community

• Proficient in reading and comprehending both written and spoken English

• Strong communication skills for clear and effective interaction

• Physical ability to stoop, bend, sit and/or stand for extended periods, perform repetitive motions, and lift and carry files and business materials

🏝️ Benefits

• Equal opportunity employment

• Work in a general office environment equipped with ergonomically designed furnishings

• Employment status remains AT-WILL at all times