Behavioral Health UM Case Manager

DRISCOLL HEALTH PLAN•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 Case Manager facilitates clinically appropriate and fiscally responsible patient care by communicating with providers, health plan medical directors, and other members of the health care and health plan team. They assess patients’ clinical findings and, in conjunction with the Physician Advisor or Health Plan Administration, established benefits, protocols, pathways, and evidence-based medicine tools, determine appropriate health care services and levels 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 role performs utilization review and case management activities, including preauthorization and concurrent or retrospective reviews, coordination with multidisciplinary teams and community resources, and participation in health plan improvement activities and committees. The Case Manager follows departmental and health plan policies, participates in on-call scheduling as directed, and communicates workload status and turnaround-time concerns to management.

Requirements

Graduate of an accredited school of Registered Nursing or Licensed Clinical Social Work (LCSW).
A minimum of three years of prior clinical experience.
Well-organized, with excellent time-management ability.
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 and effectively handle escalated customer and co-worker needs.
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 benefit from 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 and report suspected or actual quality, provider, eligibility, and compliance concerns according to policy.
Collaborate with physicians, social workers, case managers, and other multidisciplinary team members to obtain optimal outcomes for members.
Collaborate with hospital case managers to identify impediments to safe discharge promptly and develop corrective strategies to promote patient safety and positive outcomes.
Complete concurrent and/or retrospective reviews of hospital treatment appropriateness using plan-approved evidence-based criteria.
Participate in health plan performance improvement activities.
Participate in health plan committees as appropriate and when 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 approval from a manager or designee before distributing workload.
Be available for non-clinical staff activities.