Utilization Management Clinician – Tuesday to 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 facilitate healthcare service coordination.

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

• Provide utilization management services that encourage quality, cost-effective healthcare usage.

• Gather and analyze member information to promote wellness, appropriate service utilization, and economical care.

• Coordinate resources to achieve goals related to member outcomes.

• Document case notes and explanation letters, ensuring that documentation may be included in legal records.

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

• Maintain communication with inpatient facility utilization review staff regarding ongoing stays and care levels.

• Identify cases that require discharge planning and coordinate transfers and services across skilled nursing, rehabilitation, residential, outpatient, behavioral health, home health, and hospice settings.

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

• Identify and negotiate with vendors when necessary.

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

• Collaborate with multidisciplinary teams on network unavailability, out-of-network exceptions, and one-time agreements.

• Act as a primary resource for members and families in relation to health plans and navigation through the healthcare system.

• Address medical or contract interpretation inquiries 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.

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

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

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

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

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

• Adhere to privacy policies and comply with 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 medical and/or behavioral health exposure.

• Preferred experience in acute care and case management, including rehabilitation, home health, behavioral health, and hospice cases.

• Insurance industry experience is beneficial but not mandatory.

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

• Familiarity with contractual benefits and options outside of these benefits.

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

• Understanding of appropriate case management plans.

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

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

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

• Capability to keep current clinical knowledge and certifications up to date.

• Ability to work independently with little supervision.

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

• Ability to meet performance and attendance expectations.

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

• Ability to read and understand written and spoken English.

• Proficient in clear and effective communication.

• Approximately 5% travel may be required.

🏝️ Benefits

• Work from home (WFH) opportunities.

• Commitment to equal opportunity employment.

• Ergonomically designed equipment.

• A company culture that values customer service, communication, community enhancement, social justice, equity, diversity and inclusion, creativity, innovation, and excellence.