Utilization Management Clinician - RN

PacificSource Health Plans • Springfield, OR

404d

About The Position

The Utilization Management Clinician - RN at PacificSource Health Plans is responsible for coordinating healthcare services for members, ensuring they access quality and cost-effective care. This role involves collaborating with various healthcare professionals, assessing member needs, and managing utilization review processes to promote wellness and effective healthcare delivery.

Requirements

• Minimum of three years of nursing or behavioral health experience with varied medical exposure.
• Experience in acute care and case management, including rehabilitation and hospice treatment.
• Registered Nurse or clinically licensed behavioral health practitioner with a current unrestricted state license.
• Knowledge of medical and behavioral health processes, diagnoses, and procedure codes.
• Ability to use computerized systems for data recording and retrieval.

Nice To Haves

• Case Manager Certification accredited by CCMC preferred.
• Insurance industry experience helpful but not required.

Responsibilities

• Collect and assess member information pertinent to their history, condition, and functional abilities.
• Coordinate necessary resources to achieve member outcome goals and objectives.
• Accurately document case notes and letters of explanation for legal records.
• Perform concurrent review of members admitted to inpatient facilities and treatment centers.
• Maintain contact with inpatient facility utilization review personnel to ensure appropriateness of continued stay and level of care.
• Identify cases requiring discharge planning, including transfers to skilled nursing facilities and outpatient services.
• Review referral and preauthorization requests for appropriateness of care within established criteria.
• Negotiate with vendors to provide services and discounts with non-contracted providers when applicable.
• Work with multidisciplinary teams to support members effectively.
• Serve as a primary resource for members and families regarding health plan questions and navigation.
• Assist employers and agents with healthcare resource inquiries.
• Identify high-cost utilization and refer to appropriate teams as needed.
• Assist the Medical Director in developing guidelines for the Health Services Department.

Benefits

• Health insurance coverage
• Dental insurance coverage
• 401k retirement savings plan
• Paid holidays
• Flexible scheduling options

What This Job Offers

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