Utilization Management Clinician – Tuesday - Saturday

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

📋 Description

• Work in close collaboration with physicians, nurses, social workers, and a diverse group of medical and non-medical professionals to ensure effective healthcare service delivery.

• Evaluate the specific health plan benefits of members and identify additional medical, community, or financial resources available to them.

• Provide utilization management (UM) services aimed at fostering quality, cost-effective outcomes by assisting member populations in optimizing their use of healthcare services.

• Facilitate exceptional member care through fiscally responsible strategies.

• Gather and analyze member information related to their history, condition, and functional abilities to encourage wellness, appropriate utilization, and cost-effective care and services.

• Coordinate essential resources to achieve defined member outcome goals and objectives.

• Ensure accurate documentation of case notes and explanatory letters, which may be included in legal records.

• Conduct concurrent reviews of members admitted to inpatient facilities, residential treatment centers, and partial hospitalization programs.

• Maintain ongoing communication with inpatient facility utilization review personnel to verify the appropriateness of continued stays and levels of care.

• Identify cases necessitating discharge planning, including transfers to skilled nursing facilities, rehabilitation centers, and outpatient services, taking into account member co-morbid conditions.

• Review referral and preauthorization requests to assess the appropriateness of care in accordance with established evidence-based criteria.

• When applicable, identify and negotiate with suitable vendors to provide necessary services.

• If appropriate, negotiate discounts with non-contracted providers and/or refer them to the Provider Network Department for contract development.

• Collaborate with multidisciplinary teams using an integrated team-based approach to optimally support members.

⛳️ Requirements

• A minimum of three (3) years of experience in nursing or behavioral health.

• 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.

• Understanding of contractual benefits and the options available beyond those benefits.

• Familiarity with community services, providers, vendors, and facilities available to assist members.

• Knowledge of appropriate case management plans.

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

• Commitment to maintaining patient confidentiality, privacy, and health records security.

• Ability to establish and sustain relationships with community services and providers.

• Maintain a current clinical knowledge base and certifications.

• Capability to work independently with minimal supervision.

🏝️ 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.

• Options such as a flexible spending account.