Utilization Management Clinician

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

📋 Description

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

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

• Deliver utilization management services that promote high-quality, cost-effective healthcare usage.

• Gather and analyze member information to support wellness, appropriate utilization, and cost-efficient care.

• Organize resources to achieve the desired outcomes for members.

• Document case notes and letters of explanation, including records that may have legal implications.

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

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

• Identify cases necessitating discharge planning and coordinate transfers, as well as behavioral health, home health, hospice, rehabilitation, and outpatient services.

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

• Identify and negotiate with vendors, securing discounts from non-contracted providers.

• 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 navigating health plan and healthcare system challenges.

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

• Support employers and agents with questions about healthcare resources and procedures.

• Identify high-cost utilization cases and refer them to reinsurance 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 staff and operations.

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

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

• Meet department and company performance and attendance standards.

• Adhere to privacy policies and HIPAA confidentiality and security regulations.

• Perform additional duties as assigned.

⛳️ Requirements

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

• Acute care and case management experience is strongly preferred.

• Experience in rehabilitation, home health, behavioral health, and hospice treatment is highly preferred.

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

• An active, unrestricted RN, LPC, LMFT, LCSW, or PMHNP credential is required.

• Case Manager Certification accredited by CCMC is preferred.

• Comprehensive 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 of these benefits.

• Familiarity with community services, providers, vendors, and facilities.

• Knowledge of appropriate case management plans.

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

• Awareness of patient confidentiality, privacy, and health-record security.

• Ability to establish and maintain relationships with community services and providers.

• Capacity to keep current clinical knowledge and certifications up to date.

• Ability to work independently with minimal supervision as well as collaboratively within a team.

• Proficiency in reading and comprehending written and spoken English.

• Strong communication skills to convey information clearly and effectively.

• Ability to stoop, bend, sit, and/or stand for prolonged periods, perform repetitive typing, sorting, and filing, and lightly lift and carry files and business materials.

• Approximately 5% travel may be required.

🏝️ Benefits

• Flexible telecommuting policy.

• Medical insurance coverage.

• Vision insurance benefits.

• Dental insurance options.

• Incentive programs available.

• Paid time off for employees.

• Paid holidays throughout the year.

• 401(k) retirement plan.

• Opportunities for volunteering.

• Tuition reimbursement and training programs.

• Life insurance coverage.

• Flexible spending account options.

• Opportunities for personal growth and career advancement.

• Learning and development opportunities to foster career progression.

• Commitment to work-life balance.

• Training and individual development opportunities for career growth.