Utilization Management Clinician – Tuesday - Saturday

PacificSource Health Plans

Utilization Management Clinician collaborating with healthcare professionals to enhance member care and outcomes. Assessing health plan benefits and coordinating healthcare services with a focus on cost-effective solutions.

Posted 7/21/2026full-timeRemote • North Carolina • 🇺🇸 United StatesMid-LevelSenior💰 $70,950 - $106,424 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in case management, including utilization management and coordination of healthcare services, while maintaining patient confidentiality and leveraging community resources to achieve optimal member outcomes.

Highest-signal resume keywords

Registered Nurse (RN) LicenseCase Manager CertificationUtilization Management (UM)Behavioral Health ExperienceKnowledge of ICD and CPT Codes

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Case ManagementUtilization ReviewPatient AssessmentDocumentationDischarge PlanningNegotiationData RecordingCare CoordinationCommunity Resource KnowledgeBehavioral Health Processes

Soft Skills

CollaborationCommunicationIndependenceRelationship BuildingProblem 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 ServicesMember CareCost-Effective OutcomesCommunity ServicesEvidence-Based CriteriaInpatient FacilitiesResidential Treatment CentersPartial Hospitalization ProgramsContractual BenefitsPatient Confidentiality

About the role

Key responsibilities & impact

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
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

Requirements

What you’ll need

Minimum of three (3) years of nursing or behavioral health experience
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
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

Benefits

Comp & perks

Flexible telecommute policy
Medical, vision, and dental insurance
Incentive program
Paid time off and holidays
401(k) plan
Volunteer opportunities
Tuition reimbursement and training
Life insurance
Options such as a flexible spending account