Utilization Management Nurse

Looking for a way to make an impact and help people? Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource 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 develop 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 healthcare 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 achieve effective utilization of healthcare 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 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 the 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 Health 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 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 license, Licensed Professional Counselor, Licensed Marriage and Family Therapist, Licensed Clinical Social Worker, or Psychiatric Mental Health Nurse Practitioner credential required. Case Manager Certification 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; assurance of patient confidentiality, privacy, and health records security; establishment and maintenance of relationships with community services and providers; maintenance of current clinical knowledge base and certification; ability to work independently with minimal supervision; ability 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. Environment: Work inside in a general office setting with ergonomically configured equipment. Travel required approximately five percent of the time. Skills: Accountability; Collaboration; Communication (written and 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 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. #J-18808-Ljbffr