Utilization Management Clinician – Tuesday to Saturday

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

📋 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 promote quality and cost-effective healthcare use.

• Gather and analyze member information regarding their history, condition, and functional abilities.

• Coordinate resources to achieve the desired outcomes for members.

• Document case notes and explanatory letters that may serve as legal records.

• 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 stays and levels of care.

• Identify cases that require discharge planning and coordinate necessary transfers and services.

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

• Identify and negotiate with vendors when needed.

• Negotiate discounts with non-contracted providers and refer providers for contract development when appropriate.

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

• Act as the primary resource for members and families regarding health plan inquiries and healthcare navigation.

• Address medical or contract interpretation questions from 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.

• Provide backup and resources for Health Services Department staff.

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

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

• Meet departmental and company performance and attendance standards.

• Adhere to PacificSource privacy policy and HIPAA confidentiality and security regulations.

• Perform additional duties as assigned.

⛳️ Requirements

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

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

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

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

• Understanding of suitable case management plans.

• Proficiency in utilizing computerized systems for data entry and retrieval.

• Ability to maintain patient confidentiality, privacy, and security of health records.

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

• Keep current with clinical knowledge and certification.

• Ability to work autonomously with minimal supervision.

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

• Proficient in reading and comprehending both written and spoken English.

• Communicate clearly and effectively.

• Approximately 5% travel required.

🏝️ Benefits

• Competitive salary and performance-based incentives.

• Comprehensive health, dental, and vision insurance.

• Retirement savings plan with company match.

• Generous paid time off and holiday schedule.

• Opportunities for professional development and continuing education.