UR Case Management Specialist

Job Duties & Responsibilities

• Act as the liaison between RBH and third-party payers in advocating for medical necessity authorization
• Provide utilization information to third-party payors and facilitate any physician-to-physician (peer to peer) reviews or expedited appeals
• Act as a liaison between RBH, third-party payers, and non-RBH providers to ensure aftercare is complete with appointments scheduled
• Attend and participate in interdisciplinary treatment team meetings
• Review active medical records to ensure medical necessity documentation requirements are met and escalate documentation or quality care issues if needed
• Communicate with utilization review (UR) leadership, admitting leadership, and clinical leadership regarding the quality of documentation within the medical record
• Collaborate with admitting and clinical leadership in providing feedback, education and training to clinical staff regarding medical necessity documentation
• Initiate the physician advisory review process as needed
• Provide leadership in the facilitation between Rogers programs by acting as the primary liaison between admissions, clinical teams, payer strategies and patient financial services to ensure medical necessity authorization, single-case agreements or self-pay deposits are obtained
• Inform UR leadership of any sensitive cases or potential cases involving payer strategies that may lead to contractual arrangements
• Work with regulatory and/or quality department to identify, investigate, or resolve issues that place patients or Rogers Behavioral Health at risk
• Maintain a list of specific resources to be used in accordance with best practice
• Adhere to established Standard Work and ensure all documentation standards are met within required time frame
• Provide leadership in aftercare planning for all patients by coordinating the discharge planning process between all stakeholders including, but not limited to, patients/families, Rogers’ clinicians, outpatient providers, insurance case managers, county services, legal, etc. to establish discharge plans that meet the clinical needs of the patient
• Assess patient/support system needs for resources based on medication management, psychotherapy, ongoing medical care, housing/placement concerns, financial needs, community support, and county-based support
• Ensure the discharge planning process begins at admission by obtaining collateral input from the referral source and other treatment providers, obtaining necessary authorization for the release of patient information as required by Hospital policy, and ensure patient demographics are accurate between RBH and third-party payer systems
• Provide ongoing collaboration with the patient/family and treatment team on continuing care needs to further develop or adjust the aftercare plan throughout the treatment process
• Complete aftercare plans prior to discharge including scheduling aftercare appointments or arranging transfer to other Rogers’ programs
• Document all steps of the discharge planning process in the electronic health record
• Arrange for community resources to facilitate discharge
• Provide all needed documentation to other providers to facilitate successful transition through the continuum of care
• Populate and maintain referent/provider database in the electronic health record
• Support process improvement initiatives within the UR department
• Provide assistance to new UR case management specialists and care advocates with understanding and adhering to standard work
• Assist in the creation and implementation of new standard work by identifying areas of waste and collaborating with others to identify solutions
• Assist with the collection of data to facilitate continuous improvement
• Provide professional communication and customer service to all stakeholders
• Provide ongoing communication with clinical teams, admissions, and third-party UR and case management teams about the status of cases
• Assist patient financial services staff with the investigation of any reimbursement problems
• Communicate with patients and/or family members concerning aftercare planning, insurance benefits, authorizations, aftercare recommendations, self-pay arrangements, and/or medical necessity denials from third-party payors for continued stays
• Educate patients and family members regarding any costs of care that may occur in the course of treatment

Education/Training Requirements

• Bachelor’s Degree is required; Behavioral Science or Human Services is preferred
• Two (2) years previous work experience required, office or hospital setting preferred
• Knowledge of managed care, Medicaid and Medicare is preferred
• Utilization review experience in a hospital, outpatient or managed care setting preferred
• Case management experience in a hospital, outpatient or managed care setting preferred
• Knowledge of the DSM, ICD-10, medical, mental health and chemical dependency diagnosis and treatment process is preferred
• Computer skills are required, including word processing, spread sheets and data processing
• Knowledge of Joint Commission documentation and medical records standards and ability to maintain accurate records
• Current American Heart Association CPR certification or American Red Cross Professional Rescue is required within thirty (30) days of date of hire. Bi-annual re-certification is required
• Formal training in the management of the aggressive patient (S.A.F.E.) is required within sixty (60) days of date of hire. Annual re-certification is required