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
Employment Status: Full-Time, Exempt
Schedule: Monday-Friday
Work Location: Remote - Must be able to support all time zones
Compensation: Pay Range: $65-75k
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
Employment Status: Full-Time, Exempt
Schedule: Monday-Friday
Work Location: Remote - Must be able to support all time zones
Compensation: Pay Range: $65-75k