Utilization Management Clinician (Tuesday - Saturday)

PacificSource Health Plans•Springfield, OR

2d•$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 clinician assesses members’ health plan benefits and available medical, community, and financial resources, and provides utilization management services intended to promote quality, cost-effective outcomes and effective use of healthcare services. The role supports outstanding member care using fiscally responsible strategies. The position conducts concurrent reviews for members receiving inpatient, residential, and partial hospitalization care; reviews referrals and preauthorization requests; coordinates resources and discharge planning; and serves as a resource for members, families, providers, employers, agents, and internal teams. Work is performed inside in a general office setting with ergonomically configured equipment, and travel is required approximately 5% of the time. The scheduled days are Tuesday through Saturday.

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 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.
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 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 read and comprehend written and spoken English and communicate clearly and effectively.

Nice To Haves

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

Responsibilities

Collect and assess member information related to 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; these records 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 care, behavioral health, home health, and hospice services, 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, 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.
Interact with PacificSource personnel to support quality customer service.
Answer internal questions requiring medical or contract interpretation, including questions referred by other departments and by 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 requirements for confidentiality and security of protected health information.
Perform other duties as assigned.