Utilization Management Clinician – Tuesday, Saturday

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

📋 Description

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

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

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

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

• Coordinate resources to meet the outcome goals for members.

• Document case notes and explanatory letters, including records that may become part of legal documentation.

• 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 coordinate transfers and services accordingly.

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

• Identify and negotiate with vendors as necessary.

• Negotiate discounts with non-contracted providers and recommend providers for contract development when suitable.

• Collaborate with multidisciplinary teams on NNA, OONE, and OTA cases.

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

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

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

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

• Assist the Medical Director in formulating guidelines and procedures for the Health Services Department.

• Support other staff and functions within the Health Services Department as needed.

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

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

• Meet the performance and attendance requirements set by the department and company.

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

• Perform additional duties as assigned.

⛳️ Requirements

• A minimum of three (3) years of experience in nursing or behavioral health with diverse exposure to medical and/or behavioral health settings.

• Strong preference for experience in acute care and case management, including rehabilitation, home health, behavioral health, and hospice treatment.

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

• An active and unrestricted RN, 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 outside of those benefits.

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

• Understanding of suitable case management plans.

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

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

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

• Keep current with clinical knowledge and certification.

• Ability to work independently with minimal oversight.

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

• Demonstrated accountability, collaboration, communication, flexibility, active listening, organizational and planning skills, problem-solving, and teamwork.

• Proficiency in reading and comprehending written and spoken English.

• Ability to communicate clearly and effectively.

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

• Approximately 5% travel is required.

🏝️ Benefits

• Flexible telecommuting policy.

• Medical, vision, and dental insurance.

• Incentive program.

• Paid time off and holidays.

• 401(k) plan.

• Opportunities for volunteer work.

• Tuition reimbursement and training programs.

• Life insurance.

• Options for flexible spending accounts.

• Opportunities for personal growth and career advancement.

• Opportunities for learning development and career progression.

• Work-life balance.

• Competitive salary.

• Training, individual development, and career advancement opportunities.