Utilization Management Clinician (Tuesday-Saturday)

Join PacificSource and help our members access quality, affordable care!

• →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.

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.