Impactful Utilization Management Clinician

pacificsource; Missouri; Hybrid; USD 75,000 - 105,000; Full time

Job summary

PacificSource in Missouri seeks a qualified health services professional with nursing or behavioral health experience to coordinate care and ensure appropriate utilization for members. The role requires an active RN license or equivalent credential and may involve case management across inpatient, residential, and outpatient settings.

Responsibilities include collecting member data, documenting case notes, reviewing referrals, and coordinating with multidisciplinary teams to support member

Qualifications

• Minimum 3 years nursing or behavioral health experience.
• Active RN license or equivalent credential.
• Experience in acute care and case management preferred.
• Insurance industry experience helpful, but not required.

Responsibilities

• Collect and assess member information to promote wellness, utilization, and cost-effective care.
• Coordinate resources to achieve member outcome goals.
• Accurately document case notes and letters for legal records.
• Perform concurrent review for inpatients, residential and partial hospitalization programs.
• Maintain contact with inpatient utilization review to ensure appropriateness of care.
• Identify discharge planning needs including transfers to facilities and home health services.
• Review referrals and preauthorizations for care within criteria sets.
• Negotiate with vendors for services when applicable.
• Coordinate with network teams for out-of-network or OTA arrangements.
• Serve as primary resource to members and families for health plan questions.

Skills

Nursing experience

Behavioral health experience

Case management

Interdisciplinary collaboration

Education

RN license

LPC

LMFT

LCSW

PMHNP

CCMC certification

Job description

PacificSource in Missouri seeks a qualified health services professional with nursing or behavioral health experience to coordinate care and ensure appropriate utilization for members. The role requires an active RN license or equivalent credential and may involve case management across inpatient, residential, and outpatient settings.

Responsibilities include collecting member data, documenting case notes, reviewing referrals, and coordinating with multidisciplinary teams to support member