Utilization Management Clinician (Tuesday - Saturday)

PacificSource Health Plans•Boise, ID

3d•$70,950 - $106,425

About The Position

The Utilization Management Clinician collaborates with physicians, nurses, social workers, and other medical and non-medical professionals to coordinate healthcare services. The role assesses members’ health plan benefits and available medical, community, and financial resources, and provides utilization management services that promote quality, cost-effective outcomes and effective use of healthcare services. The clinician facilitates member care using fiscally responsible strategies. The position reviews referrals and preauthorization requests, conducts concurrent reviews for members in inpatient, residential treatment, and partial hospitalization settings, and coordinates resources and discharge planning. The clinician serves as a resource for members and families navigating the health system, works with providers and internal teams, and helps address clinical, contractual, and service questions. The role also documents case activity, identifies high-cost utilization, supports guideline development, and contributes to Health Services Department work.

Requirements

At least three years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability.
An active, unrestricted credential as a Registered Nurse (RN), Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), Licensed Clinical Social Worker (LCSW), or Psychiatric Mental Health Nurse Practitioner (PMHNP).
Thorough 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 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.
Ability to protect patient confidentiality, privacy, and health-record security.
Ability to establish and maintain relationships with community services and providers.
Ability to maintain current clinical knowledge and certification.
Ability to work independently with minimal supervision and function as part of a collaborative, cohesive community.
Skills in accountability, collaboration, written and verbal communication, flexibility, active listening, organization and planning, problem solving, and teamwork.
Ability to stoop and bend; sit and/or stand for extended periods; perform repetitive motions such as typing, sorting, and filing; and lift and carry files and business materials.
Ability to read and comprehend written and spoken English and communicate clearly and effectively.

Nice To Haves

Experience in acute care and case management, including cases requiring rehabilitation, home health, behavioral health, and hospice treatment.
Insurance industry experience.
Case Manager Certification accredited by CCMC.

Responsibilities

Collect and assess member information about history, condition, and functional abilities to promote wellness, appropriate utilization, and cost-effective care.
Coordinate resources to achieve member outcome goals and objectives.
Document case notes and letters of explanation accurately, recognizing that they may become part of legal records.
Perform concurrent reviews of members admitted to inpatient facilities, residential treatment centers, and partial hospitalization programs.
Maintain contact with inpatient facility utilization review personnel to assess continued-stay and level-of-care appropriateness.
Identify cases requiring discharge planning, including transfers to skilled nursing facilities, rehabilitation centers, residential and outpatient services, behavioral health, home health, and hospice, while considering member comorbidities.
Review referral and preauthorization requests for appropriateness of care using established evidence-based criteria.
Identify and negotiate with appropriate vendors when applicable.
Negotiate discounts with non-contracted providers when appropriate and/or refer providers to the Provider Network Department for contract development.
Work with multidisciplinary teams using an integrated, team-based approach, including on network-not-available cases, out-of-network exceptions, and one-time agreements.
Serve as a primary resource for members and their families on health plan questions and navigating health-system issues.
Work with PacificSource personnel to ensure quality customer service.
Answer questions requiring medical or contract interpretation referred by other departments, physicians, and providers of medical services and supplies.
Assist employers and agents with questions about healthcare resources and procedures for their employees and clients.
Identify high-cost utilization and refer cases to the Large Case Reinsurance RN and Care Management team as appropriate.
Assist the Medical Director in developing Health Services Department guidelines and procedures.
Back up and support other Health Services Department staff and functions as needed.
Serve on designated committees, teams, and task groups as directed.
Represent the Health Services Department internally and externally as requested by the Medical Director.
Meet department and company performance and attendance expectations.
Follow PacificSource privacy policies and HIPAA requirements concerning confidentiality and security of protected health information.
Perform other duties as assigned.