Utilization Management Clinician

PacificSource • Portland, OR

2d • $70,950 - $106,425 • Hybrid

About The Position

PacificSource is seeking a Utilization Management Clinician to join their team. This role involves collaborating with physicians, nurses, social workers, and other professionals to coordinate healthcare services. The clinician will assess member health plan benefits and available resources, providing utilization management (UM) services to promote quality, cost-effective outcomes and help member populations effectively utilize healthcare services. The goal is to facilitate outstanding member care using fiscally responsible strategies.

Requirements

• Minimum of three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required.
• 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 required.
• 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.
• Must be able to function as part of a collaborative, cohesive community.
• Accountability
• Collaboration
• Communication (written/verbal)
• Flexibility
• Listening (active)
• Organizational skills/Planning and Organization
• Problem Solving
• Teamwork

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.
• Case Manager Certification as accredited by CCMC preferred.

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.
• Act as backup and be a resource for other Health Services Department staff and functions as needed.
• Serve on designated committees, teams, and task groups, as directed.
• Represent the Heath Services Department, both internally and externally, as requested by Medical Director.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

Benefits

• Our Values We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business: We are committed to doing the right thing. We are one team working toward a common goal. We are each responsible for customer service. We practice open communication at all levels of the company to foster individual, team and company growth. We actively participate in efforts to improve our many communities-internally and externally. We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community. We encourage creativity, innovation, and the pursuit of excellence.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed