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　　Join PacificSource and help our members access quality, affordable care!

　　PacificSource is an equal opportunity employer. All qualifiedapplicants will receive consideration for employment without regard tostatus as a protected veteran or a qualified individual with adisability, or other protected status, such as race, religion, color,national origin, sex, sexual orientation, gender identity or age.

　　Diversity and Inclusion: PacificSource values the diversity of thepeople we hire and serve. We are committed to creating a diverseenvironment and fostering a workplace in which individual differencesare appreciated, respected and responded to in ways that fully developand utilize each person\'s talents and strengths.

　　Collaborate closely with physicians, nurses, social workers and a widerange of medical and non-medical professionals to coordinate delivery ofhealthcare services. Assess the member\'s specific health plan benefitsand the additional medical, community, or financial resources available.Provide utilization management (UM) services which promote quality,cost-effective outcomes by helping member populations achieve effectiveutilization of healthcare services. Facilitate outstanding member careusing fiscally responsible strategies.

　　Essential Responsibilities:

　　Collect and assess member information pertinent to member\'shistory, condition, and functional abilities in order to promotewellness, appropriate utilization, and cost-effective care andservices.Coordinate necessary resources to achieve member outcome goals andobjectives.Accurately document case notes and letters of explanation which maybecome part of legal records.Perform concurrent review of members admitted to inpatientfacilities, residential treatment centers, and partialhospitalization programs.Maintain contact with the inpatient facility utilization reviewpersonnel to assure appropriateness of continued stay and level ofcare.Identify cases that require discharge planning, including transferto skilled nursing facilities, rehabilitation centers, residential,and outpatient to include behavioral health, home health, andhospice services while considering member co-morbid conditions.Review referral and preauthorization requests for appropriateness ofcare within established evidence-based criteria sets.When applicable, identify and negotiate with appropriate vendors toprovide services.When appropriate, negotiate discounts with non-contracted providersand/or refer such providers to Provider Network Department forcontract development.Work with multidisciplinary teams utilizing an integrated team-basedapproach to best support members, which may include working togetheron network not available (NNA), out of network exceptions (OONE),and one-time agreements (OTA).Serve as primary resource to member and family members for questionsand concerns related to the health plan and in navigating throughthe health systems issues.Interact with other PacificSource personnel to assure qualitycustomer service is provided.Act as an internal resource by answering questions requiring medicalor contract interpretation that are referred from other departments,as well as physicians and providers of medical services andsupplies.Assist employers and agents with questions regarding healthcareresources and procedures for their employees and clients.Identify high cost utilization and refer to Large Case ReinsuranceRN and Care Management team as appropriate.Assist Medical Director in developing guidelines and procedure forHealth Services Department.Supporting Responsibilities:

　　Act as backup and be a resource for other Health Services Departmentstaff and functions as needed.Serve on designated committees, teams, and task groups, as directed.Represent the Heath Services Department, both internally andexternally, as requested by Medical Director.Meet department and company performance and attendance expectations.Follow the PacificSource privacy policy and HIPAA laws andregulations concerning confidentiality and security of protectedhealth information.Perform other duties as assigned.Work Experience: Five years of nursing or behavioral healthexperience with varied medical and/or behavioral health exposure andcapability required. Experience in acute care, case management,including cases that require rehabilitation, home health, behavioralhealth and hospice treatment strongly preferred. Insurance industryexperience helpful, but not required.

　　Education, Certificates, Licenses: Registered Nurse or a ClinicallyLicensed Behavioral Health Practitioner with current unrestricted statelicense. Within 6 months of hire licensure may need to include Oregon,Montana, Idaho and/or other states as needed. Case Manager Certificationas accredited by CCMC preferred.

　　Knowledge