Utilization Management Clinician (Tuesday - Saturday)

Looking for a way to reputed company an impact and help people? Join reputed company and help our members access quality, reputed company! reputed company is an equal opportunity employer. reputed company reputed company applicants will receive consideration for employment without regard to status as a protected veteran or a reputed company individual with a disability, or other protected status, such as race, religion, reputed company, sex, sexual orientation, gender identity, national reputed company, genetic information or age. reputed company values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully reputed company and utilize each person’s talents and strengths. Collaborate closely with physicians, nurses, social workers and a wide range of medical and non-medical professionals to coordinate delivery of reputed company services. Assess the member’s specific health plan benefits and the additional medical, community, or financial resources available. Provide utilization management (UM) services which promote quality, cost-effective outcomes by helping member populations reputed company effective utilization of reputed company services. Facilitate outstanding member care using fiscally responsible strategies. Essential 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 reputed company member outcome goals and objectives. Accurately document case notes and letters of explanation which may become part of legal records. reputed company reputed company 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 reputed company 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 reputed company established evidence-based criteria sets. reputed company applicable, identify and negotiate with appropriate vendors to provide services. reputed company 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 reputed company to the health plan and in navigating through the health systems issues. Interact with other reputed company 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 reputed company 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 reputed company privacy policy and HIPAA laws and regulations concerning confidentiality and reputed company of protected health information. reputed company other duties as assigned. reputed company 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 reputed company insurance and state-mandated benefits. Understanding of contractual benefits and options available reputed company 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 reputed company. Establishes and maintains relationships with community services and providers. Maintains reputed company clinical knowledge reputed company and certification. Ability to work independently with minimal supervision. Must be reputed company to function as part of a collaborative, cohesive community. Competencies: Adaptability Building Customer Loyalty Building Strategic Work Relationships Building Trust reputed company Improvement Contributing to Team reputed company 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 reputed company that range. reputed company 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 reputed company 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 reputed company 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 reputed company this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of reputed company duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at reputed company times. Apply To This Job