Utilization Management Clinician

PACIFICSOURCE

. 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 and maintaining compliance with privacy policies and regulations.

Highest-signal resume keywords

Registered Nurse (RN) LicenseCase Manager Certification (CCMC)Medical And Behavioral Health KnowledgeUtilization Management ServicesCommunity Services Coordination

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Case Management PlansICD CodesCPT CodesHealthcare NavigationData Recording And RetrievalDischarge PlanningConcurrent ReviewsNegotiation SkillsDocumentation SkillsHealth Insurance Knowledge

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 ServicesUtilization ReviewPatient ConfidentialityHIPAA ComplianceCommunity Resources

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, or financial resources
Provide utilization management services promoting quality, cost-effective healthcare utilization
Collect and assess member information to promote wellness, appropriate utilization, and cost-effective care
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 transfers to skilled nursing, rehabilitation, residential, outpatient, behavioral health, home health, and hospice services
Review referral and preauthorization requests using evidence-based criteria
Identify and negotiate with appropriate vendors when applicable
Negotiate discounts with non-contracted providers or refer providers for contract development
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
Provide internal medical or contract interpretation support to 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 guidelines and procedures
Provide backup and resources for Health Services staff and functions
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 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
Ability to communicate clearly and effectively
Ability to stoop and bend, sit and/or stand for extended periods, perform repetitive typing, sorting and filing, and light lifting and carrying