Utilization Management Clinician (Tuesday-Saturday)

PacificSource Health Plans•Portland, OR

3d•$70,950 - $106,425•Onsite

About The Position

PacificSource seeks a Utilization Management Clinician to coordinate healthcare services with physicians, nurses, social workers, and other medical and non-medical professionals. The clinician assesses members’ health plan benefits and available medical, community, and financial resources, and provides utilization management services to support quality, cost-effective care and effective use of healthcare services. This role facilitates member care using fiscally responsible strategies and serves as a resource for members, families, providers, employers, agents, and internal teams. The position performs reviews of inpatient and other treatment, supports discharge planning, coordinates resources, documents case information, and collaborates with multidisciplinary teams. The clinician also contributes to departmental guidelines and procedures, supports other Health Services staff, and follows privacy and HIPAA requirements. The schedule is Tuesday through Saturday. The work is performed in a general office setting with ergonomically configured equipment, and travel is required approximately 5% of the time.

Requirements

At least three years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability.
An 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.
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 maintain patient confidentiality, privacy, and health records security.
Ability to establish and maintain relationships with community services and providers.
Ability to maintain a current clinical knowledge base 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 while performing core job functions, perform repetitive motions such as typing, sorting, and filing, and lift and carry files and business materials lightly.
Ability to read and comprehend written and spoken English and communicate clearly and effectively.

Nice To Haves

Experience in acute care or 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 the appropriateness of continued stay and level of care.
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 co-morbid conditions.
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, 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, out-of-network exception, and one-time agreement cases as applicable.
Serve as a primary resource for members and family members with health plan questions and help them navigate health system issues.
Interact with PacificSource personnel to ensure quality customer service.
Answer internal questions requiring medical or contract interpretation, including questions referred from 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.
Provide backup and support to 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 policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
Perform other duties as assigned.