Utilization Management Clinician

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

📋 Description

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

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

• Provide utilization management services that promote quality and cost-effective outcomes.

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

• Coordinate resources to achieve goals related to member outcomes.

• 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 utilization review personnel regarding continued stays and level of care.

• Identify cases that require discharge planning and coordinate the necessary transfers and 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.

• Collaborate with multidisciplinary teams on network-not-available situations, out-of-network exceptions, and one-time agreements.

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

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

• Assist employers and agents with inquiries regarding healthcare resources and procedures.

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

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

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

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

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

• Meet the performance and attendance expectations of the department and company.

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

• 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 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, and procedure codes including ICD and CPT Codes, as well as health insurance and state-mandated benefits.

• Familiarity with contractual benefits and options available outside of these benefits.

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

• Understanding of appropriate case management plans.

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

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

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

• Keeps current clinical knowledge and certification up to date.

• Ability to work independently with minimal supervision.

• Must be able to function as part of a collaborative and cohesive community.

• Ability to read and comprehend both written and spoken English.

• Communicate clearly and effectively.

• Stoop and bend; sit and/or stand for extended periods; perform repetitive motions such as typing, sorting, and filing; and engage in light lifting and carrying of files and business materials.

🏝️ Benefits

• Equal opportunity employment.

• Work in a general office setting equipped with ergonomically designed equipment.

• Employment remains AT-WILL at all times.