Utilization Management Clinician – Tuesday - Saturday

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

📋 Description

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

• Evaluate members’ health plan benefits alongside accessible medical, community, and financial resources.

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

• Gather and evaluate member information to enhance wellness, appropriate utilization, and economical care.

• Coordinate resources to meet member outcome objectives.

• Document case notes and letters of explanation.

• Conduct concurrent reviews for inpatient, residential treatment, and partial hospitalization admissions.

• Maintain communication with inpatient facility utilization review personnel regarding continued stays and care levels.

• Identify cases that require discharge planning and facilitate transitions to skilled nursing, rehabilitation, residential, outpatient, behavioral health, home health, and hospice services.

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

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

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

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

• Address medical or contract interpretation questions from internal 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.

• Support the Medical Director with guidelines and procedures of the Health Services Department.

• Provide assistance to other Health Services Department staff and functions.

• Participate in committees, teams, and task groups.

• Represent the Health Services Department both internally and externally.

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

• Adhere to privacy policies and HIPAA regulations.

• Perform additional duties as assigned.

⛳️ Requirements

• A minimum of three 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.

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

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

• Familiarity with health insurance and state-mandated benefits.

• Understanding of contractual benefits and options beyond contractual benefits.

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

• Insight into 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 sustain relationships with community services and providers.

• Commitment to maintaining current clinical knowledge and certification.

• Ability to work independently with minimal supervision.

• Capacity to function as part of a collaborative team.

• Approximately 5% travel required.

• Proficient in reading and understanding written and spoken English.

• Clear and effective communication abilities.

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

🏝️ Benefits

• Work-from-home arrangement.

• Support/preference for Case Manager Certification accredited by CCMC.

• An equal opportunity and diversity-focused work environment.