Utilization Review Case Manager

Position Summary:

The UR Case Manager will be responsible for managing an active caseload of clients at the following Levels of Care: Partial Hospitalization, and Intensive Outpatient. S/he acts as a liaison between insurance companies, admissions, and clinical teams. The UR Case Manager is responsible for gathering required information, effectively case-building, and collaborating with members of both the Utilization Review Team and interdisciplinary Treatment Team to ensure optimization of each client’s coverage and benefits. S/he is responsible for communicating updates to appropriate representatives at the insurance company, the Clinical Team, and as directed by the Manager/Director of Utilization Review. 

Essential Job Functions:

• Complete Initial, concurrent, Peer, and retrospective reviews in a timely manner to ensure continuous coverage.
• ‪Utilize clinical information and knowledge of Medical Necessity criteria to effectively communicate plans of care to insurance case managers, facility staff, and healthcare partners.
• Conduct and manage initial, concurrent, and discharge reviews to optimize benefits and utilization.
• Represents the UR Department in a professional and positive way to other Departments and the company as a whole.
• Consistently demonstrate excellent communication, prioritization, and multi-tasking skills.
• ‪Maintains contact with the clients’ families and keeps them updated on current insurance authorization updates, Peer Reviews, and Denials.
• Document all activities in a detailed manner in applicable CRM/EMR.
• ‪Collaborate with Clinicians and the multidisciplinary team to obtain necessary clinical documentation for reviews and ensure effective utilization of resources.
• ‪Participate in weekly Treatment Team and Continuing Care Meetings as appropriate.
• ‪Prepares and submit Appeal documentation (including rationales) to the appropriate entities as indicated
• Coordinate, schedule, and complete Peer-to-Peer and Appeal reviews.
• Complete weekly Treatment Team notes and provides updates to the Psychiatrist as requested by the Director/Manager.
• Track all data concerning current LOS and information pertaining to LOS, as well as discharge LOS and information pertaining to discharge LOS.
• Hold training to clinical staff and other individuals needed, concerning medical necessity, insurance requirements, as well as other areas needed that are directly affect by LOS
• Follow chain of command both within the Department and outside of the Department.

Core Competencies:

• Proficient in MS Office applications, which include Outlook, Word, Excel, and PowerPoint.
• Ability to build and sustain trusting relationships with diverse individuals and groups.
• Ability to maintain confidentiality of sensitive information and adhering to ethical standards.
• Actively offering assistance to team members when needed and celebrating team achievements collectively.
• Ability to establish and maintain cooperative relationships with community-based organizations, patients, families, vendors, and other resources to promote client services, care, education, and advocacy.

Knowledge, Education, & Experience:

• Minimum of Bachelor's Degree in Mental Health.
• Licensed LMFT, LCSW, LVN, or RN preferred but not required
• Prior experience in doing utilization review for substance abuse facilities preferred
• Strong knowledge of ASAM dimensions1-6
• Knowledge of DSM-Vcodes
• Knowledge of SUD, IOP, and Mental Health programs