Utilization Management Clinician - RN

PacificSource Health Plans • Bend, OR

400d

About The Position

The position at PacificSource involves collaborating with healthcare professionals to coordinate the delivery of healthcare services for members. The role focuses on assessing member health plan benefits, providing utilization management services, and ensuring quality, cost-effective care. The individual will work closely with multidisciplinary teams to support members in navigating healthcare systems and resources, while also maintaining compliance with privacy regulations.

Requirements

• Minimum of three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required.
• Registered Nurse or a clinically licensed behavioral health practitioner with current unrestricted state license.
• 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.
• Understanding of contractual benefits and options available outside contractual benefits.
• Working knowledge of community services, providers, vendors and facilities available to assist members.

Nice To Haves

• Experience in acute care, case management, including cases that require rehabilitation, home health, behavioral health and hospice treatment strongly preferred.
• Insurance industry experience helpful, but not required.

Responsibilities

• Collect and assess member information pertinent to member's history, condition, and functional abilities.
• 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 services.
• Review referral and preauthorization requests for appropriateness of care within established evidence-based criteria sets.
• Identify and negotiate with appropriate vendors to provide services when applicable.
• 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.
• Serve as primary resource to member and family members for questions and concerns related to the health plan.
• 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.
• 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

• Health insurance coverage
• Dental insurance coverage
• Vision insurance coverage
• 401k benefit for retirement savings plan
• Paid holidays
• Flexible scheduling
• Professional development opportunities
• Employee discount programs

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Insurance Carriers and Related Activities
• Education Level: No Education Listed