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.

• Assess member health plan benefits along with available medical, community, and financial resources.

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

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

• Coordinate resources to achieve the desired outcomes and objectives for members.

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

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

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

• 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 utilizing evidence-based criteria sets.

• Identify and negotiate with suitable 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.

• Respond to medical or contract interpretation inquiries directed by other departments, physicians, and providers.

• Assist employers and agents with questions regarding 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 Health Services Department guidelines and procedures.

• 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 requested by the Medical Director.

• Meet the performance and attendance expectations set by the department and company.

• Adhere to PacificSource privacy policies and HIPAA laws and regulations.

• Perform other assigned duties.

⛳️ Requirements

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

• Preferred experience in acute care and case management, especially cases needing rehabilitation, home health, behavioral health, and hospice treatment.

• Insurance industry experience 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, procedure codes including ICD and CPT Codes, health insurance, and state-mandated benefits.

• Awareness of contractual benefits and the options available outside of them.

• Familiarity with community services, providers, vendors, and facilities available to assist members.

• Understanding of effective case management plans.

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

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

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

• Commitment to maintaining current clinical knowledge and certification.

• Capacity to work independently with minimal supervision.

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

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

• Effective communication skills.

• Physical ability to stoop and bend, sit and/or stand for extended periods, perform repetitive motions, and engage in light lifting/carrying.

• Willingness to travel approximately 5% of the time.

🏝️ Benefits

• Comprehensive health insurance coverage.

• Retirement savings plans with company contributions.

• Opportunities for professional development and continued education.

• Flexible work schedules to support work-life balance.

• Employee assistance programs for personal and professional support.