Healthcare Utilization Nurse or Behavioral Health ...

Make a difference and help others! Join PacificSource and play a crucial role in helping our members access quality, affordable healthcare! We are looking for dedicated professionals to become a part of our team. At PacificSource, we are an equal opportunity employer, valuing diversity and ensuring that all qualified applicants are considered for employment without regard to race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information, age, or other protected status. In this vital role, you will collaborate with physicians, nurses, social workers, and various medical and non-medical professionals to coordinate healthcare services for our members. Your responsibilities will include assessing members' health plan benefits and connecting them to additional medical, community, or financial resources. Ensure our members receive outstanding care while promoting quality and cost-effective outcomes. Key Responsibilities: Collect and evaluate member information related to health histories and functional abilities to enhance wellness and appropriate care usage. Coordinate essential resources to achieve member outcome goals. Document case notes and letters that may be used in legal contexts. Conduct concurrent reviews for members in inpatient settings, residential centers, and partial hospitalization programs. Maintain ongoing communication with facility utilization review personnel to ensure the continued appropriateness of care. Identify cases requiring discharge planning for various services, considering members' co-morbid conditions. Review referral and preauthorization requests for care appropriateness based on evidence-based criteria. If applicable, identify and negotiate with vendors for necessary services. Collaborate with multidisciplinary teams to address member needs and navigate complex cases. Serve as a primary resource for members and their families on health plan inquiries. Ensure quality customer service through interactions with PacificSource personnel. Act as an internal resource for medical or contract interpretation queries from other departments. Assist employers with questions regarding healthcare resources and procedures. Identify high-cost utilization cases and appropriately refer them to relevant teams. Support the Medical Director in developing Health Services Department guidelines. Additional Responsibilities: Provide support to other Health Services staff as needed. Participate in committees and teams as directed. Represent the Health Services Department internally and externally as needed. Meet performance and attendance expectations set by the department. Adhere to privacy policies and HIPAA regulations. Perform other duties as assigned. Qualifications: Experience: Minimum of three years of nursing or behavioral health experience preferred, with a strong background in acute care and case management. Education and Licenses: Registered Nurse or a clinically licensed behavioral health practitioner with an unrestricted state license required. Preferred: Case Manager Certification accredited by CCMC. Knowledge and Skills: Extensive understanding of medical and behavioral health processes, diagnoses, and procedure codes. Familiarity with health insurance and state-mandated benefits. Ability to effectively navigate community services and healthcare options. Strong organizational, problem-solving, and communication skills. Ability to work independently and as part of a cohesive team. Values We Embrace: Commitment to integrity and doing what's right. Collaboration towards common goals. Responsibility for delivering excellent customer service. Open communication at all levels for growth. Active participation in community improvement. Advocacy for social justice, equity, diversity, and inclusion. Encouragement of creativity and excellence in our work. Physical Requirements: Ability to sit or stand for extended periods and perform repetitive movements. Light lifting and carrying of files and materials. Clear communication in written and spoken English. This position offers a unique opportunity to make a profound impact on members' lives while working in a supportive and values-driven environment.

Created: 2026-03-06