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PacificSource Health Plans · 1 week ago

Utilization Management Clinician (Tuesday-Saturday or Sunday-Thursday)

Springfield, OR

Full-time

Onsite

Mid Level

3+ years exp

PacificSource Health Plans is seeking a Utilization Management Clinician to help members access quality, affordable care. The role involves collaborating with various healthcare professionals to coordinate care, assess member benefits, and provide utilization management services to promote effective healthcare utilization.

CommunitiesCustomer ServiceNon Profit

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

Qualification

Registered NurseCase ManagementBehavioral HealthICDCPT CodesHealth Insurance KnowledgeCommunicationCollaborationProblem SolvingOrganizational SkillsTeamwork

Required

Minimum of three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required

Registered Nurse or a clinically licensed behavioral health practitioner with current unrestricted state license

Within six (6) months of hire licensure may need to include Oregon, Montana, Idaho and/or other states as needed

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

Preferred

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