Utilization Management Clinician

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

📋 Description

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

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

• Deliver utilization management services that encourage quality and cost-effective healthcare utilization.

• Gather and analyze member information to support wellness, appropriate utilization, and cost-efficient care.

• Coordinate resources to meet member outcome objectives.

• Prepare case notes and letters of explanation.

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

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

• Identify cases that need discharge planning and coordinate transfers and services in behavioral health, home health, hospice, rehabilitation, and skilled nursing.

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

• Identify and negotiate with vendors and non-contracted providers.

• Support multidisciplinary teams regarding network exceptions and one-time agreements.

• Act as a primary resource for members and families navigating health plan and healthcare-system challenges.

• Address medical or contract interpretation inquiries from 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.

• Assist the Medical Director with Health Services guidelines and procedures.

• Provide backup support, participate in committees and task groups, and represent the Health Services Department.

• Meet performance and attendance standards, ensuring compliance with privacy and HIPAA regulations.

• Perform additional duties as assigned.

⛳️ Requirements

• A minimum of three years of nursing or behavioral health experience with diverse medical and/or behavioral health exposure.

• Strong preference for experience in acute care and case management.

• Preferred experience with rehabilitation, home health, behavioral health, and hospice treatment.

• Helpful but not mandatory insurance industry experience.

• Required: Active, unrestricted RN, LPC, LMFT, LCSW, or PMHNP credential.

• Preferred: Case Manager Certification accredited by CCMC.

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

• Understanding of contractual benefits and options outside of them.

• Familiarity with community services, providers, vendors, and facilities.

• Knowledge of appropriate case management plans.

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

• Awareness of patient confidentiality, privacy, and health-record security.

• Current clinical knowledge base and certification.

• Capability to work independently with minimal supervision as well as collaboratively within a team.

• Ability to meet performance and attendance standards.

• Proficient in reading and understanding written and spoken English.

• Clear and effective written and verbal communication skills.

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

🏝️ Benefits

• Work from home arrangement.

• Equal opportunity workplace.

• Diverse and inclusive work environment.

• Ergonomically configured equipment.

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

• Approximately 5% travel.