Utilization Management Clinician

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This is a full-time remote Utilization Management Clinician opportunity that functions independently within the Department and reports directly to the Medicare Concurrent UM Team. The schedule is Monday-Friday, 8:30am-5pm. No weekends or holidays.

The Utilization Management Clinician utilizes clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program for Medicare DSNP and Medicare Advantage. Applies critical thinking and clinical judgment grounded in evidence-based care and clinical practice guidelines for behavioral health and/or medical conditions, based on program focus. Supports care coordination and benefit management across complex member needs, with attention to quality, service, and appropriate resource use.

Key Responsibilities

• Apply clinical expertise to review and evaluate treatment plans across various levels of care, ensuring alignment with evidence-based standards, clinical guidelines, and applicable benefit coverage criteria.
• Coordinate, monitor, and assess healthcare service options to help ensure members receive appropriate, cost-effective care.
• Collect and assess clinical information to determine coverage recommendations, including discharge planning, transitions of care, and coordination of services for members with complex medical, behavioral health, and psychosocial needs.
• Collaborate with providers, care teams, and interdisciplinary partners to facilitate optimal treatment outcomes and support continuity of care.
• Identify high-risk members and connect them with appropriate internal programs, services, community resources, or additional supports.
• Recognize opportunities to enhance the quality and effectiveness of healthcare services while optimizing benefit use for a complex, high-need member population.
• Serve as a clinical resource to internal teams and external partners regarding utilization management processes, member needs, and coordination requirements.
• Perform responsibilities while working primarily at a computer, including extended periods of phone communication.

Required Qualifications

• Must be able to work the posted schedule. The role requires rendering decisions within mandated turnaround times; therefore, schedule flexibility is limited.
• Active, current, and unrestricted Registered Nurse licensure in the state of residence with psychiatric specialty, certification, or relevant experience.
• 1+ years of behavioral health utilization review/utilization management experience required.
• 3+ years of experience in an inpatient hospital setting working with behavioral health members. Experience must be recent, or supported by continuous, behavioral health-focused work since the inpatient setting experience.
• Ability to multitask, prioritize, and effectively adapt to a fast-paced changing environment.
• Ability to demonstrate experience working independently.

Preferred Qualifications

• Experience with application of Medicare Benefit Policy manual.
• Experience working with geriatric or chronically mentally ill populations.
• Experience supporting high-risk member populations.
• Strong computer proficiency, including navigating multiple systems and accurate keyboarding.

Education

• Master's-level behavioral health degree, or Registered Nurse licensure with behavioral health experience
• Associate degree required; BSN preferred.

Licensure

• Active, current, and unrestricted Master's-level behavioral health clinical license in the state of residence (LMSW, LCSW, LISW, LPC, or comparable), or Registered Nurse licensure in the state of residence with psychiatric specialty, certification, or relevant experience.

Anticipated Weekly Hours

40

Time Type

Full-time

Pay Range

$60,522.00 - $129,615.00

Benefits

This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.