Behavioral Health UM Case Manager

Driscoll Children's Hospital•Corpus Christi, TX

About The Position

The Utilization Management Case Manager coordinates and efficiently utilizes health care resources to provide quality care throughout the continuum of care. The role facilitates clinically appropriate and fiscally responsible patient care through communication with providers, health plan medical directors, and other health care and health plan team members. The Case Manager assesses patients’ clinical findings and, in conjunction with the Physician Advisor or Health Plan Administration, applies established benefits, protocols, pathways, and evidence-based medicine tools to determine appropriate health care services and level of care. Case management may be prospective, concurrent, or retrospective. The Case Manager communicates with care and service providers to ensure appropriate levels of care. The position requires a graduate of an accredited school of Registered Nursing or Licensed Clinical Social Work (LCSW), and at least three years of prior clinical experience. One year of acute inpatient case management or managed care case/utilization management experience is preferred. Knowledge of Medicaid criteria, managed care contracts, reimbursement mechanisms, and criteria sets such as InterQual is preferred.

Requirements

Graduate of an accredited school of Registered Nursing or Licensed Clinical Social Work (LCSW).
At least three years of prior clinical experience.
Well-organized, with excellent time-management skills.
Ability to establish and maintain effective working relationships with customers and peers.
Ability to operate personal computer programs and complex medical management software.
Ability to understand complex situations and interpersonal dynamics to handle escalated customer and co-worker needs effectively.
Strong Microsoft Office skills.
Excellent communication skills.

Nice To Haves

Knowledge of Medicaid criteria and guidelines.
Knowledge of managed care contracts and guidelines.
Working knowledge of reimbursement mechanisms, including third-party requirements.
Current working and demonstrated knowledge of criteria sets such as InterQual.
One year of acute inpatient case management or managed care case/utilization management experience.

Responsibilities

Participate in timely, quality completion of preauthorization or case management activities.
Apply plan benefits consistently for each line of business.
Identify members with health care needs who may be appropriate for available disease management programs.
Make appropriate referrals to departments such as Population Health, Utilization Management, Social Services, Quality Management, Compliance, and Provider Relations.
Coordinate services with community resources as appropriate.
Report suspected or actual quality concerns and provider, eligibility, or compliance issues according to policy.
Collaborate with physicians, social workers, Case Managers, and other multidisciplinary team members to obtain optimal member outcomes.
Collaborate with hospital case managers to promptly identify impediments to safe discharge and develop corrective action strategies to promote patient safety and positive outcomes.
Complete concurrent and/or retrospective reviews of hospital treatment for appropriateness using plan-approved evidence-based criteria.
Participate in health plan performance improvement activities and committees as appropriate or requested.
Participate in on-call scheduling as directed by management.
Adhere to departmental and health plan policies.
Accept other assignments from management as requested and comply with management principles of delegation.
Communicate workload status and turnaround-time discrepancies to management as necessary; obtain manager or designee approval before distributing workload.
Be available for non-clinical staff activities.