Utilization Management Clinician - Behavioral Health

PacificSource • Helena, MT

343d

About The Position

Looking for a way to make an impact and help people? Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age. Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

Requirements

• Minimum of three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required.
• Experience in acute care, case management, including cases that require rehabilitation, home health, behavioral health and hospice treatment strongly preferred.
• Registered Nurse or a clinically licensed behavioral health practitioner with current unrestricted state license.
• Within six (6) months of hire licensure may need to include Oregon, Montana, Idaho and/or other states as needed.
• Case Manager Certification as accredited by CCMC preferred.
• Thorough knowledge and understanding 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 outside contractual benefits.
• Working knowledge of community services, providers, vendors and facilities available to assist members.
• Understanding of appropriate case management plans.
• Ability to use computerized systems for data recording and retrieval.
• Assures patient confidentiality, privacy, and health records security.
• Establishes and maintains relationships with community services and providers.
• Maintains current clinical knowledge base and certification.
• Ability to work independently with minimal supervision.

Responsibilities

• Collect and assess member information pertinent to member's history, condition, and functional abilities in order to promote wellness, appropriate utilization, and cost-effective care and services.
• Coordinate necessary resources to achieve member outcome goals and objectives.
• Accurately document case notes and letters of explanation which may become part of legal records.
• Perform concurrent review of members admitted to inpatient facilities, residential treatment centers, and partial hospitalization programs.
• Maintain contact with the inpatient facility utilization review personnel to assure appropriateness of continued stay and level of care.
• Identify cases that require discharge planning, including transfer to skilled nursing facilities, rehabilitation centers, residential, and outpatient to include behavioral health, home health, and hospice services while considering member co-morbid conditions.
• Review referral and preauthorization requests for appropriateness of care within established evidence-based criteria sets.
• When applicable, identify and negotiate with appropriate vendors to provide services.
• When appropriate, negotiate discounts with non-contracted providers and/or refer such providers to Provider Network Department for contract development.
• Work with multidisciplinary teams utilizing an integrated team-based approach to best support members, which may include working together on network not available (NNA), out of network exceptions (OONE), and one-time agreements (OTA).
• Serve as primary resource to member and family members for questions and concerns related to the health plan and in navigating through the health systems issues.
• Interact with other PacificSource personnel to assure quality customer service is provided.
• Act as an internal resource by answering questions requiring medical or contract interpretation that are referred from other departments, as well as physicians and providers of medical services and supplies.
• Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients.
• Identify high cost utilization and refer to Large Case Reinsurance RN and Care Management team as appropriate.
• Assist Medical Director in developing guidelines and procedures for Health Services Department.

Benefits

• Diversity and Inclusion initiatives
• Opportunities for professional development
• Collaborative work environment

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree
• Number of Employees: 501-1,000 employees