Utilization Management Clinician

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

📋 Description

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

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

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

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

• Coordinate resources to meet member outcome goals and objectives.

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

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

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

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

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

• Identify and negotiate with appropriate vendors when necessary.

• Negotiate discounts with non-contracted providers and refer providers for contract development when suitable.

• 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 plan inquiries and healthcare-system navigation.

• Engage with PacificSource personnel to guarantee quality customer service.

• Provide medical or contract interpretation support to departments, physicians, and providers.

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

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

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

• Provide backup and support to other 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 departmental and company performance and attendance expectations.

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

• Execute other duties as assigned.

• Travel 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 is required.

• 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 outside of contractual benefits.

• Practical knowledge of community services, providers, vendors, and facilities available to assist members.

• Understanding of suitable case management plans.

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

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

• Capability to establish and sustain relationships with community services and providers.

• Ability to keep current clinical knowledge base and certification.

• Capacity to work independently with minimal supervision.

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

• Proficient in reading and comprehending both written and spoken English.

• Skilled in communicating clearly and effectively.

• Ability to stoop, bend, sit and/or stand for extended periods, perform repetitive typing/sorting/filing motions, and engage in light lifting/carrying.

🏝️ Benefits

• Equal opportunity employment.

• Work indoors in a general office environment with ergonomically configured equipment.

• Employment remains AT-WILL at all times.