Utilization Management Clinician – Tuesday, Saturday

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

📋 Description

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

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

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

• Gather and analyze member information to enhance wellness, appropriate utilization, and cost-effective care.

• Coordinate resources to achieve goals for member outcomes.

• Record case notes and prepare letters of explanation.

• Conduct concurrent reviews of members in inpatient, residential treatment, and partial hospitalization settings.

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

• Identify cases that necessitate discharge planning and facilitate transitions to post-acute, behavioral health, home health, hospice, and outpatient services.

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

• Identify and negotiate with vendors when applicable.

• Negotiate discounts with non-contracted providers and refer providers for contract negotiations.

• Support multidisciplinary efforts on network-not-available, out-of-network exceptions, and one-time agreements.

• Act as a primary resource for members and families navigating health plan and health system issues.

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

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

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

• Aid the Medical Director in the development of Health Services guidelines and procedures.

• Provide backup support for Health Services Department staff and functions.

• Participate in committees, teams, and task groups.

• Represent the Health Services Department both internally and externally.

• Meet departmental and company performance and attendance standards.

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

• Perform additional duties as assigned.

⛳️ Requirements

• A minimum of three years of nursing or behavioral health experience with a diverse background in medical and/or behavioral health settings.

• Acute care and case management experience is strongly preferred, particularly in rehabilitation, home health, behavioral health, and hospice cases.

• Experience within the insurance industry is beneficial but not mandatory.

• An active, unrestricted RN license, LPC, LMFT, LCSW, or 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.

• Understanding of contractual benefits and options beyond those benefits.

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

• Familiarity with appropriate case management plans.

• Capability to utilize computerized systems for data entry and retrieval.

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

• Ability 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.

• Function effectively as part of a collaborative and cohesive community.

• Meet performance and attendance expectations.

• Proficient in reading and comprehending written and spoken English.

• Demonstrate effective and clear communication skills.

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

• Approximately 5% travel may be required.

🏝️ Benefits

• Flexible telecommute policy.

• Medical, vision, and dental insurance.

• Incentive program.

• Paid time off and holidays.

• 401(k) plan.

• Volunteer opportunities.

• Tuition reimbursement and training.

• Life insurance.

• Flexible spending account options.

• Opportunities for personal growth and advancement.

• Opportunities for learning development and career advancement.

• Work-life balance.

• Competitive wages and outstanding benefits.

• Training, individual development, and career advancement opportunities.