Clinical Utilization Case Manager

JAMES BARRY-ROBINSON INSTITUTE•Norfolk, VA

1d•Onsite

About The Position

The Barry Robinson Center is a premier behavioral health system dedicated to improving the lives of children since 1933, with a special focus on serving military-connected youth. Located on a beautiful campus in Norfolk, Virginia. Home to one of the largest military communities in the world, we provide residential treatment, outpatient services, and foster care to children ages 11–17 whose families serve our nation. We are hiring a Clinical Utilization Case Manager to provide a supportive clinical link between the clinical team, the Center, and external payor/case management entities to support justification of continued inpatient client RTC and appropriate documentation of clinical care. The Clinical Utilization Case Manager reviews, collates, and reports information necessary to support clinical service delivery, maintains accurate and detailed UCM case management record/files (as required by regulatory agencies and managed care companies), and collects and evaluates data/documentation necessary to continually support the quality of care provided to served client. Schedule: Onsite Monday - Friday 8:30am - 5:00pm

Requirements

Active LPN/RN licensure preferred.
BA or BS in a Human Services field preferred.
Minimum of one (1) year clinical experience in an inpatient mental health setting.
Excellent organizational, writing and proofreading skills.
Verbal ability to effectively communicate with others.
Sensitivity to content of reports being generated and to potential liability issues.
Ability to work independently and set priorities.
Critical time management and organization skills required.
Ability to apply given criteria to information presented in appropriate narrative format required by payor and make appropriate interpretations.
Numerical and quantitative ability required to prepare statistical data and/or reports
Ability to work with other providers in securing appropriate discharge support to support client with stepdown/discharge needs to different care level
Ability to manage cases with a minimum caseload of 30 patients effectively and proficiently and meet critical submission deadlines.
Knowledgeable and proficient in using Microsoft Office applications (Microsoft Outlook, PowerPoint, Excel)
Familiarity with electronic systems (EMRs, payor portals, electronic payroll systems)

Nice To Haves

Payor experience preferred.

Responsibilities

Interface/Communicate with external payor(s) sources and case management companies to provide required documentation to justify the need for the authorized level of care and submission within required/requested payor dates.
Conduct ongoing clinical utilization review for assigned cases-incorporating review of all documentation (both paper and electronic) in support of medical necessity review of the case that allows for continued RTC level of care.
Submission of formal updated clinical status report to payor within allocated/scheduled timeline IAW payor guidelines
Report any and all significant case problematic areas/concerns for events that may lead to audit and/or could result in a lack of continued approval for authorization to direct supervisor.
Monitor plan to verify that service delivery is consistent with all required payor criteria.
Work cooperatively with designated staff and all depts to ensure adequate service delivery and documentation submitted into the medical records.
Collect and assess data/ documentation for QI monitoring of cases and offer alternative ideas for improvement.
Report documentation issues to HIMs dept for tracking/monitoring, along with communicating to appropriate assigned dept for resolution.
Assure Treatment Plan/Staffing reports contain accurate data, documentation, and all required elements (required by payor) are included to support appropriate clinical service delivery.
Review problem areas/goal objectives in treatment plan to monitor and be able to report client program progress during treatment to outside payor sources.
Ongoing review of medical record to identify continued client problem areas, and all issues associated with continued treatment.
Work collaboratively with members of the treatment team to update review and goal objectives on a monthly basis.
Offer recommendations/suggestions for problem resolution, to include in person, use of electronic platforms (Zoom, Teams, Outlook, etc.).
Produce a payor required discharge summary for each child within the required time frame for case close out.
Other tasks as assigned.