Utilization Review Case Management Specialist

Summary:

The UR Case Management Specialist provides leadership in the facilitation of the treatment process from admission to discharge. The UR Case Management Specialist monitors the treatment process, acting on behalf of the best interest of the patients, their families, and Rogers Behavioral Health to manage risk, ensure quality patient care and cost/quality outcomes. The UR Case Management Specialist collaborates with other departments to resolve identified care delivery issues at Rogers Behavioral Health.

Job Duties & Responsibilities:

Coordinate and Track Patient Care

• 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/familyand 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.

Promote department goals as well as the mission of Rogers Behavioral Health.

• Communicate goals to fellow staff members.
• Demonstrate measurable goal achievement.
• Maintain department policies and procedures.
• Include requirements and guidelines from external agencies (eg. Joint Commission, State of Wisconsin).
• Educate new staff regarding regulations or requirements of those functions that relate to their areas or departments, as directed.

Demonstrate understanding of Joint Commission and other regulatory agency compliance regulations.

• Involve self in the learning and application of standards relevant to the Admission Services department.
• Participate in in-services, seminars, and other meetings to increase involvement and awareness of regulations.
• Involve self in the education of other disciplines regarding the department’s regulations.

Participate in committees, team meetings, and team projects, as directed.

• Demonstrate punctuality and preparedness.
• Demonstrate effective communication skills and exhibit good organizational skills.
• Contribute in a positive, solution-focused manner.

Conduct self in a professional manner.

• Demonstrate organizational skills that promote timely response to all inquiries and to task completion.
• Communicate with all individuals in a positive and professional manner.
• Attempt to resolve individual issues with peers in a positive, calm manner, with a focus on solution.
• Communicate concerns and provide solutions.
• Attend outside seminars and/or educational classes to promote professional growth.
• Demonstrate a positive and professional attitude toward parties outside Rogers Behavioral Health (payers, patient families, vendors, etc.).
• Comply with the hospital’s policies and procedures, including Human Resources, Infection Control, and Employee Health policies and programs.
• Project a professional image by wearing appropriate, professional attire.
• Work independently with minimal supervision.

Perform other duties as assigned.

Additional Job Description:

Physical/Mental Demands:

• Able to be flexible with work assignments, including schedule changes, case load size, program additions and changes in policy and procedures.
• Must be able to work independently and complete assignments within specified times. 
• Position is full-time salaried with possibility of working some weekends and/or holidays as needed. 
• Able to perform in a professional manner in stressful situations with patients, their families, payers, and Rogers Behavioral Health staff.
• Able to apply common sense principles and to resolve problems independently.
• Must be detail oriented, courteous, and respectful of Rogers staff members, patients, their families, and payers.
• Work may take place remotely or inside the Hospital or other buildings on the Rogers Behavioral Health campus. Physical requirements include walking between buildings on campus and occasional exposure to combative or aggressive patients.
• Exceptional communication skills required to deal effectively with patients/families, third-party payers, professional staff, and management.
• Able to be accessible to patients, show support, and conduct appropriate interactions. Display proper judgement and respond in a proactive and non-intrusive manner, regardless of a patient’s behavior. 
• Able to work cooperatively and supportively with all Hospital staff; show courtesy, respect, and willingness to work out problems on a one-on-one basis. 
• Verbal, written, and hearing ability required to interact with patients and employees. Numerical ability required to maintain records and operate a computer.
• Able to plan, control, and direct all aspects of employee relations. Tact required to interact effectively with employees and professional staff. Logical thinking and discretion required to make decisions in initiating and implementing policies, procedures, and standards.
• Physically/Mentally able to perform job duties as verified by a physical exam by a licensed physician, per post-employment physical.

Education/Training Requirements:

• Bachelor’s Degree or four (4) years of direct utilization review, discharge planning, or case management experience in a behavioral health setting is required.
• 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.
   

With a career at Rogers, you can look forward to a Total Rewards package of benefits, including:

• Health, dental, and vision insurance coverage for you and your family 
• 401(k) retirement plan 
• Employee share program 
• Life/disability insurance 
• Flex spending accounts  
• Tuition reimbursement 
• Health and wellness program
• Employee assistance program (EAP)

Through UnitedHealthcare, UMR and HealthSCOPE Benefits creates and publishes the Machine-Readable Files on behalf of Rogers Behavioral Health.To link to the Machine-Readable Files, please visitTransparency in Coverage (uhc.com)