UM Case Manager/Appeals Coordinator

UHS•Auburn Hills, MI

About The Position

The Utilization Management Case Manager/ Appeal Coordinator has responsibility for organizing and conducting the managed care process and managing the appeal 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. In addition, this position is responsible for identifying cases for appeal, submitting those appeals, and tracking their status.

Requirements

Bachelor Degree in social work, psychology, counseling or nursing required.
Valid license in the State of Michigan as a Limited or fully licensed (LBSW, RN, LLMSW, LMSW, LLP, TLLP, LPC, LMFT, etc.) required.
A minimum of 2 years of post-graduate related experience in psychiatric or substance abuse treatment required.
Experience in appeals process required.

Nice To Haves

Master’s degree in social work, psychology, or counseling preferred.
Hospital utilization review/utilization management experience preferred
Familiarity with managed health care process, medical terminology, experience in case management, discharge planning, and/or utilization review preferred.

Responsibilities

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, payer 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.
Identifies denied cases and researches appeal process for all payers. Tracks and logs denial reason and appeal status. Prepares appeal letters, submits and tracks status of appeals. Participates and contributes in denial meeting