Utilization Management Clinician – Tuesday to Saturday

PacificSource Health Plans

. Collaborate with physicians, nurses, social workers, and medical and non-medical professionals to coordinate healthcare services .

Posted 10/23/2026full-timeRemote • South Carolina • United StatesMid-LevelSenior💰 $70,950 - $106,425 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in case management, healthcare coordination, and utilization management, with a strong understanding of medical and behavioral health processes. Proficient in navigating healthcare resources, maintaining patient confidentiality, and collaborating with multidisciplinary teams to achieve optimal member outcomes.

Highest-signal resume keywords

Registered Nurse (RN) LicenseCase Manager CertificationKnowledge of ICD and CPT CodesExperience in Utilization ManagementUnderstanding of Behavioral Health Processes

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Healthcare CoordinationUtilization ManagementCase Management PlansData Recording and RetrievalMedical DocumentationDischarge PlanningContract NegotiationCommunity Resource KnowledgeEvidence-Based Criteria ReviewPatient Privacy and Confidentiality

Soft Skills

Effective CommunicationRelationship BuildingIndependent WorkCollaborationProblem Solving

Certifications & Qualifications

Registered Nurse (RN)Licensed Professional Counselor (LPC)Licensed Marriage and Family Therapist (LMFT)Licensed Clinical Social Worker (LCSW)Psychiatric Mental Health Nurse Practitioner (PMHNP)

Industry Keywords

Healthcare ServicesBehavioral HealthUtilization ReviewCommunity ServicesHealth InsuranceState-Mandated BenefitsInpatient FacilitiesResidential Treatment CentersPartial Hospitalization ProgramsVendor Negotiation

About the role

Key responsibilities & impact

Collaborate with physicians, nurses, social workers, and medical and non-medical professionals to coordinate healthcare services
Assess members’ health plan benefits and available medical, community, and financial resources
Provide utilization management services promoting quality, cost-effective healthcare utilization
Collect and assess member information regarding history, condition, and functional abilities
Coordinate resources to achieve member outcome goals
Document case notes and letters of explanation that may become legal records
Perform concurrent reviews for members in inpatient facilities, residential treatment centers, and partial hospitalization programs
Maintain contact with inpatient facility utilization review personnel regarding continued stay and level of care
Identify cases requiring discharge planning and coordinate transfers and services
Review referral and preauthorization requests using evidence-based criteria
Identify and negotiate with vendors when applicable
Negotiate discounts with non-contracted providers and refer providers for contract development when appropriate
Work with multidisciplinary teams on network-not-available, out-of-network exceptions, and one-time agreements
Serve as primary resource for members and families regarding health plan questions and healthcare navigation
Answer medical or contract interpretation questions from departments, physicians, and providers
Assist employers and agents with healthcare resource and procedure questions
Identify high-cost utilization and refer cases to reinsurance and care management teams
Assist the Medical Director in developing Health Services Department guidelines and procedures
Provide backup and resources for Health Services Department staff
Serve on designated committees, teams, and task groups
Represent the Health Services Department internally and externally as requested
Meet department and company performance and attendance expectations
Follow PacificSource privacy policy and HIPAA confidentiality and security requirements
Perform other duties as assigned

Requirements

What you’ll need

Minimum of three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required
Active, unrestricted Registered Nurse (RN) license, Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), Licensed Clinical Social Worker (LCSW), or Psychiatric Mental Health Nurse Practitioner (PMHNP) credential required
Case Manager Certification as accredited by CCMC preferred
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
Ability to maintain patient confidentiality, privacy, and health records security
Ability to establish and maintain relationships with community services and providers
Maintains current clinical knowledge base and certification
Ability to work independently with minimal supervision
Ability to function as part of a collaborative, cohesive community
Ability to read and comprehend both written and spoken English
Communicate clearly and effectively
Approximately 5% travel required