Utilization Management Clinician

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

📋 Description

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

• Evaluate members' health plan benefits alongside available medical, community, or financial resources.

• Deliver utilization management services, ensuring quality and cost-effective healthcare utilization.

• Gather and assess member information to encourage wellness, appropriate utilization, and cost-effective care.

• Organize resources to meet member outcome 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 concerning continued stay and level of care.

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

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

• Identify and negotiate with suitable vendors when necessary.

• Negotiate discounts with non-contracted providers or refer providers for contract development.

• 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 navigation.

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

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

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

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

• Offer backup and resources for Health Services staff and functions.

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

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

• Meet departmental and company performance and attendance expectations.

• Adhere to privacy policies and HIPAA confidentiality and security 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.

• 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 options available beyond those benefits.

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

• Understanding of suitable case management plans.

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

• Ability to maintain patient confidentiality, privacy, and secure health records.

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

• Keeps current with clinical knowledge and certification.

• Ability to work independently with minimal supervision.

• Ability to operate effectively as part of a collaborative and cohesive community.

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

• Ability to communicate clearly and effectively.

• Capacity to stoop and bend, sit and/or stand for extended periods, perform repetitive typing, sorting and filing, as well as light lifting and carrying.

🏝️ Benefits

• Competitive salary and comprehensive benefits package.

• Opportunities for professional development and advancement.

• Supportive work environment fostering collaboration and teamwork.