Utilization Management Clinician

4 months ago

Bend, United States PacificSource Full time
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, national origin, sex, sexual orientation, gender identity or age.

Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences 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 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.
Work Experience: Five 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: Registered Nurse or a Clinically Licensed Behavioral Health Practitioner with current unrestricted state license. Within 6 months of hire licensure may need to include Oregon, Montana, Idaho and/or other states as needed. 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, Communication, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork

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.

  • Utilization Management Specialist

    2 weeks ago

    Bend, Oregon, United States PacificSource Full time

    PacificSource Career OpportunityWe are seeking a dedicated and compassionate Utilization Management Clinician to join our team at PacificSource. As a key member of our organization, you will play a vital role in helping our members access quality, affordable care.About the Role:Collaborate with healthcare providers to ensure seamless care coordination and...

  • Utilization Management Specialist

    2 weeks ago

    Bend, Oregon, United States PacificSource Full time

    Make a Difference in HealthcarePacificSource is seeking a dedicated Utilization Management Clinician to help our members access quality, affordable care. As a key member of our team, you will play a vital role in ensuring our members receive the best possible healthcare outcomes.About the Role:Collaborate with healthcare providers to develop effective care...

  • Utilization Management Coordinator I

    4 weeks ago

    Bend, United States PacificSource Full time

    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,...

  • Special Functions Clinician

    6 days ago

    Bend, Oregon, United States PacificSource Full time

    Job SummaryPacificSource is seeking a highly skilled Special Functions Clinician to join our team. As a key member of our Health Services Department, you will play a critical role in ensuring the quality and integrity of our medical services.Key ResponsibilitiesCoordinate and collaborate with internal and external stakeholders to ensure compliance with audit...

  • Project Manager Electric Utilities

    2 weeks ago

    North Bend, Oregon, United States Leidos Full time

    Job Title: Project Manager Electric UtilitiesAt Leidos, we are seeking a highly skilled Project Manager to oversee and coordinate projects for a large electric utility client in the Pacific Northwest. As a Project Manager, you will be responsible for managing complex projects and programs related to the planning, design, and construction of electrical grid...

  • Lead Behavioral Health Clinician

    4 weeks ago

    Bend, United States Blue Rose Consulting Group, Inc. Full time

    Lead Behavioral Health Clinician OpportunityBlue Rose Consulting Group, Inc. is seeking a highly skilled and experienced Lead Licensed Behavioral Health Clinician to join our team in support of our work with a federal client in Big Bend, Texas.This role is open to US Citizens ONLY.We are looking for a seasoned professional with a strong background in leading...

  • Mental Health Clinician

    2 weeks ago

    South Bend, Indiana, United States Gpac Full time

    Job Title: Psychiatric Mental Health Nurse PractitionerJob Summary:We are seeking a skilled Mental Health Clinician to join our team at GPAC. As a Psychiatric Nurse Practitioner, you will provide comprehensive mental health services to adults with serious long-term mental health illnesses.Responsibilities:Conduct assessments and develop treatment...

  • Senior Behavioral Health Clinician

    2 weeks ago

    South Bend, Indiana, United States UnitedHealth Group Full time

    Transforming Behavioral Health Care DeliveryAt Optum, we're revolutionizing the way clinicians work and live. As a Senior Behavioral Health Clinician - Therapist, you'll be an integral part of our vision to make healthcare better for everyone.We're connecting care to create a seamless health journey for patients across care settings. Our holistic approach...

  • Advanced Practice Clinician

    2 weeks ago

    Bend, Oregon, United States Optum Full time

    Optum House Calls: A New Approach to HealthcareAt Optum, we're revolutionizing the way healthcare is delivered. Our House Calls program brings comprehensive care directly to patients in the comfort of their own homes. As a key member of our team, you'll play a vital role in shaping the future of healthcare.Key Responsibilities:Conduct thorough in-home...

  • Home Health Clinician

    2 weeks ago

    Bend, Oregon, United States Optum Full time

    Unlock a Rewarding Career with OptumAt Optum, we're revolutionizing healthcare by providing seamless, patient-centered care. As a House Calls Physician Assistant, you'll play a vital role in delivering high-quality, compassionate care to patients in the comfort of their own homes.Our House Calls program is designed to provide annual clinical assessments,...

  • Case Manager RN

    2 weeks ago

    Bend, Oregon, United States St. Charles Health System Full time

    Job Title: RN Case ManagerSt. Charles Health System is seeking a skilled RN Case Manager to join our team. As a key member of our Care Coordination department, you will play a vital role in ensuring the delivery of high-quality, patient-centered care.Job Summary:The RN Case Manager will provide clinically based case management to support the delivery of...

  • RN Case Manager

    6 days ago

    Bend, Oregon, United States St. Charles Health System Full time

    Job Title: RN Case ManagerSt. Charles Health System is seeking a skilled RN Case Manager to join our team. As a RN Case Manager, you will be responsible for providing clinically based case management to support the delivery of effective and efficient patient care.Key Responsibilities:Utilize the nursing process of assessment, diagnosis, planning,...

  • Restaurant Manager

    6 months ago

    Bend, United States Pyramid Global Hospitality Full time

    Overview We are looking for a highly motivated and analytical individual to join our team as Restaurant Manager. The Restaurant Manager is a proactive solution seeker, they lead by example, don’t settle for the normal, and continuously encourage and engage their team members. They will provide the strategic leadership required to achieve the fiduciary and...

  • RN Case Manager

    1 month ago

    Bend, United States Mosaic Medical Full time

    Description The RN Case Manager (RNCM) is responsible for performing case management services for at-risk or high-risk patients at Mosaic Community Health. This at-risk or high-risk population may include patients with complex medical conditions, and/or socioeconomic and mental health co-morbidities. Using the Nursing Process, assesses, plans, implements,...

  • RN Case Manager

    1 month ago

    Bend, United States Mosaik Medical Full time

    The RN Case Manager (RNCM) is responsible for performing case management services for at-risk or high-risk patients at Mosaic Community Health. This at-risk or high-risk population may include patients with complex medical conditions, and/or socioeconomic and mental health co-morbidities. Using the Nursing Process, assesses, plans, implements, coordinates,...

  • Fire and Emergency Response Manager

    2 weeks ago

    Bend, Oregon, United States PacifiCorp Full time

    Job SummaryPacifiCorp is seeking a highly skilled Fire and Emergency Response Manager to join our team. As a key member of our organization, you will be responsible for providing public safety information during emergency response, training, and exercise support for external stakeholders. This role requires frequent overnight travel and work during nights,...

  • Operations Manager

    1 month ago

    Bend, Oregon, United States The Wonderful Company Full time

    Operations TechnicianAre you a motivated and experienced manufacturing leader looking to drive innovation and growth in a transformative industry? Do you have a passion for supporting your teammates and driving process control?Suterra, a leading biopesticide company, is seeking a skilled Operations Technician to join our operations leadership team. As an Ops...

  • RN Case Manager

    2 weeks ago

    Bend, Oregon, United States St. Charles Health System Full time

    Job Title: RN Case ManagerSt. Charles Health System is seeking a skilled RN Case Manager to join our team. As a RN Case Manager, you will be responsible for providing clinically based case management to support the delivery of effective and efficient patient care.Key Responsibilities:Utilize the nursing process of assessment, diagnosis, planning,...

  • HR Manager

    3 weeks ago

    Bend, United States Hooker Creek Full time

    Hooker Creek is proud to be a Central Oregon, locally owned full service construction materials provider. We are an award winning company providing , , , and , and trucking. We always strive to provide excellent customer service and quality products. We are recruiting for a Human Resources Manager to oversee the Company's critical human resources functions...

  • Operations Manager

    2 weeks ago

    Bend, Oregon, United States The Wonderful Company Full time

    Operations Technician/Areas SupervisorAre you a motivated and experienced manufacturing leader looking to drive innovation and growth in a transformative industry? Do you have a passion for supporting your teammates and driving process control?Suterra, a leading biopesticide company, is seeking a talented Operations Technician/Area Supervisor to join our...