Utilization Management Clinician

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

📋 Description

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

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

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

• Gather and assess member information pertaining to their history, condition, and functional capabilities.

• Coordinate resources to achieve desired member outcome goals.

• 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 necessitate discharge planning and coordinate transfers and services accordingly.

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

• Identify and negotiate with suitable vendors.

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

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

• Act as a primary resource for members and their families regarding health plan inquiries and healthcare navigation.

• Interact with PacificSource personnel to deliver quality customer service.

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

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

• Provide backup and resources for staff within the Health Services Department.

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

• Represent the Health Services Department both internally and externally upon request.

• Meet departmental and company performance and attendance standards.

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

• Perform additional duties as assigned.

• Operate in a general office setting with approximately 5% travel required.

⛳️ 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.

• 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 of medical and behavioral health processes, diagnoses, care modalities, ICD and CPT procedure codes, health insurance, and state-mandated benefits is essential.

• Understanding of contractual benefits and options available outside of contractual benefits is necessary.

• Proficient knowledge of community services, providers, vendors, and facilities.

• Familiarity with appropriate case management plans.

• Ability to utilize computerized systems for data recording and retrieval.

• Knowledge regarding patient confidentiality, privacy, and security of health records.

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

• Ability to stay current with clinical knowledge and certification.

• Ability to work independently with minimal oversight.

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

• Proficient reading and comprehension skills in both written and spoken English.

• Strong ability to communicate clearly and effectively.

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

🏝️ Benefits

• Equal opportunity employment.

• Work-from-home location designation.

• Ergonomically configured equipment.

• Opportunities for professional development through maintaining current clinical knowledge and certification.

• Participation in committees, teams, and task groups.

• At-will employment.