Lead Utilization Review, Case Manager

UHS•Auburn Hills, MI

3d•Onsite

About The Position

Havenwyck Hospital is seeking a dynamic and talented Quality Improvement Specialist to join our team of compassionate, dedicated professionals. The Lead Utilization Management (UM) Case Manager has responsibility for daily case assignments to the UM staff and the daily monitoring, tracking, and reporting of Medicare Certificates. The Lead UM Case Manager demonstrates understanding of the UM Review Process and acts as a resource for UM staff. The Lead UM Case Manager, under the direction of the Director of UM, develops procedures for UM departmental activities and processes. The Lead UM Case Manager has responsibility for organizing and conducting the managed care process. These duties shall be directed toward supporting the hospital's mission in the pursuit of excellence in care/service and will include (but not limited to): conducting timely admission and continued stay record reviews with external payers, utilizing approved criteria to make determinations of medical necessity and level of care planning, verifying active treatment by completing internal audit reviews within approved time frames, assisting the treatment team when indicated in the discharge planning process, and acting as liaison with MD/Clinical Treatment Team and external agencies. Report authorizations, denials, and documentation concerns, as well as collaborate effectively across departments to minimize denials/facilitate optimal use of hospital resources.

Requirements

Master’s degree in social work, psychology, or counseling; or a Bachelor’s degree in nursing required.
Unrestricted and fully licensed (RN, MSW, LLMSW, LMFT, LP, LPC, etc.) required.
A minimum of 2 years of post-graduate related experience in psychiatric or substance abuse treatment required.
Able to establish professional relationships with all healthcare providers, work independently and collaboratively, have strong communication and organizational skills and attention to detail, and able to follow and manage multiple patient cases concurrently.
Experience with managed health care processes, medical terminology, experience in case management, discharge planning, and/or utilization review.
Strong organizational, writing and speaking skills are required, as well as effective communication and interpersonal skills, the ability to work with a broad array of community-based service providers and an understanding of all applicable regularity guidelines.

Nice To Haves

Experience in settings that include inpatient or partial hospitalization preferred.
Hospital utilization review/utilization management experience preferred.

Responsibilities

On a daily basis, monitors admissions and continued stay reviews for RTC. Conducts medical necessity audits and chart reviews as needed. Provides coverage for the department in the absence of the UM Manager.
Manages the assignment of cases to the UM staff and ensures equitable distribution of caseload.
Monitors, tracks and reports Medicare Certificates and ensures their accurate completion by contacting the appropriate staff or physician.
Demonstrates higher understanding of the UM Review Process and acts as a resource for UM staff. Under the direction of the UM Manager or Director, develops/documents procedures for UM departmental activities and processes.
Through clinical skills (experience and knowledge), reports to external insurance and review entities an accurate presentation of the medical management of a patient’s illness, length of stay and care alternatives available within the confines on the client’s benefits and financial resources.
Communicates with the Treatment Team (physicians, nursing staff, social workers, etc.) as necessary to advocate for the patient’s clinical treatment within the confines on the client’s benefits and financial resources
Using clinical skills (experience and knowledge) assists the team in ensuring the completeness and accuracy of the medical record.
Conducts phone, online and fax reviews with managed care providers and relays clinical data in a professional, assertive, clear and organized manner
Maintains a positive rapport with managed care providers; acts as a representative of Havenwyck Hospital.
Communicates results of reviews with physicians and team via direct contact, phone calls and chart stickers. Communicates specific criteria and special requirement of managed care regarding discharge planning, family sessions, and treatment plans.
Refers cases to the Physician Advisor/designee.
Informs physician of need to contact the managed care reviewers and follows up to ensure call is made and ascertain the number of days obtained.
Keeps accurate record of days assigned to patients and when the next review is necessary. Keeps accurate accounting of authorized days from admission to discharge.
Monitors and tracks the certification and re-certification process for Medicare patients to make certain all state and federal reporting guidelines are met.
Maintains a flow of information by documenting in internal electronic record (MIDAS) any information necessary for treatment team members to follow up on a case.
Ensures accurate documentation of authorization status and provides appropriate information to the hospital fiscal department to assist in the timely filing of claims, which, in turn, facilitates the accurate and appropriate reimbursement for services rendered.
Reviews cases on a daily basis, checking for discharges and day hospital admission and relaying pertinent information
Acts as a facilitator for the provider, payor and patient in utilizing benefits in the most efficient and effectual manner.
Has a working knowledge of insurance verification and benefits.
Possess clinical skills including specific knowledge of diagnosis and dynamics involved in the treatment of psychiatric illnesses for patients of all ages.
Attends hospital mandatory training/in-services as required in a timely manner.