Utilization Management Clinician

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.

Supporting Responsibilities: 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.

SUCCESS PROFILE Work Experience: Minimum of three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required.

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.

Education, Certificates, Licenses: 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.

Case Manager Certification as accredited by CCMC preferred.

Knowledge

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.

Competencies

• Adaptability Building Customer Loyalty Building Strategic Work Relationships Building Trust Continuous Improvement Contributing to
• Team
• Success
• Planning and
• Organizing
• Work
• Standards
• Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.

Skills

• Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork Compensation Disclaimer The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.
• Base
• Range: $70,950.00 - $106,424.99 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.
• Physical
• Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer

This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.