Utilization Management Clinician

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

📋 Description

• Collaborate with physicians, nurses, social workers, as well as medical and non-medical professionals to facilitate the coordination of healthcare services.

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

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

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

• Coordinate resources to fulfill member outcome goals and objectives.

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

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

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

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

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

• Identify and negotiate with suitable vendors.

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

• 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 excellent customer service and respond to medical or contract interpretation queries from personnel, physicians, and providers.

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

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

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

• Serve as a backup and resource for staff and functions within the Health Services Department.

• Participate in committees, teams, and task groups.

• Represent the Health Services Department both internally and externally.

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

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

• 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, rehabilitation, home health, behavioral health, and hospice treatment is strongly preferred.

• 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 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.

• Understanding of contractual benefits and alternatives available beyond contractual benefits.

• Familiarity with community services, providers, vendors, and facilities that can assist members.

• Understanding of appropriate case management plans.

• Proficiency in utilizing computerized systems for data recording and retrieval.

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

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

• Keep current with clinical knowledge base and certification.

• Ability to work independently with minimal supervision.

• Capacity to function as part of a collaborative and cohesive community.

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

• Ability to communicate clearly and effectively.

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

🏝️ Benefits

• Equal opportunity employment.

• Ergonomically configured work equipment.

• Work-from-home location designation.

• Employment remains at-will.