Clinical Utilization Case Manager
JAMES BARRY-ROBINSON INSTITUTE
Summary
The Clinical Utilization Case Manager is the clinical link between our treatment team, the Center, and external payors and case management entities. This role would support the justification of continued residential treatment (RTC) care, ensure clinical documentation is accurate and complete, and maintain case files as required by regulatory agencies and managed care companies.
Job description
The ideal candidate is an organized, independent case manager who can translate quality care into clear, payor-ready documentation, and who is committed to supporting military-connected youth and their families.
Responsibilities
- Communicate with payors and case management companies, submitting documentation to justify the authorized level of care by required deadlines
- Conduct ongoing utilization review of paper and electronic records to support medical necessity for continued RTC care, and submit updated clinical status reports per payor guidelines
- Monitor service delivery for consistency with payor criteria, and report issues that could trigger an audit or jeopardize authorization to your supervisor
- Verify that treatment plans and staffing reports are accurate and include all payor-required elements
- Review treatment plan problem areas and goals to report client progress to payors
- Work with the treatment team monthly (in person or via Zoom, Teams, Outlook) to update reviews and goals and recommend solutions
- Collect and assess data for QI monitoring, suggest improvements, and report documentation issues to HIM and the responsible department
- Partner with departments and outside providers to ensure documentation is complete and to secure discharge and step-down support
- Complete the payor-required discharge summary within the required timeframe for case close-out
Requirements
- Minimum 1 year of clinical experience in an inpatient mental health setting
- Ability to manage a caseload of at least 30 clients and meet critical submission deadlines
- Strong writing, proofreading, organizational, and time management skills; able to work independently and set priorities
- Ability to apply payor criteria to clinical information and write appropriate narrative reports
- Quantitative skills to prepare statistical data and reports
- Sensitivity to report content and liability issues
- Proficiency in Microsoft Office (Outlook, PowerPoint, Excel) and familiarity with EMRs and payor portals
- Preferred: Active LPN/RN licensure; BA/BS in a Human Services field; payor experience
Benefits
- Medical, Dental & Vision
- 403(b) Retirement Plan
- Company Paid Life Insurance
- Long-Term Disability Insurance
- Paid Annual Leave
- Paid Sick Leave
- 8 Paid Holidays
- Tuition Reimbursement
- Public Service Loan Forgiveness
- Employee Assistance Program
Company overview
The James Barry-Robinson Institute is a specialized mental health care organization dedicated to providing comprehensive behavioral health services. As a healthcare provider focused on mental wellness, the institute offers a range of therapeutic interventions and support programs for individuals facing various mental health challenges. The organization operates with a patient-centered approach, emphasizing evidence-based treatments and personalized care plans. While specific details about the institute's founding and exact service offerings are not available in the current search results, organizations with similar names typically provide outpatient counseling, psychiatric services, and specialized mental health programs. The institute likely serves its community through clinical services, educational outreach, and collaborative partnerships with other healthcare providers. Mental health care institutions like the James Barry-Robinson Institute play a crucial role in addressing the growing need for accessible and quality mental health services, contributing to overall community wellbeing and supporting individuals in their recovery journeys.