UR Case Management Specialist

Rogers Memorial Hospital•Oconomowoc, WI

About The Position

The UR Case Management Specialist provides leadership in facilitating the treatment process from admission through discharge. The specialist monitors care, advocates for the best interests of patients and their families, and supports Rogers Behavioral Health in managing risk and achieving quality patient care and cost/quality outcomes. The role collaborates across departments to resolve care-delivery issues and serves as a liaison among Rogers Behavioral Health, patients and families, third-party payers, and other providers. The specialist coordinates utilization review and discharge planning, including obtaining medical-necessity authorizations, supporting payer reviews and appeals, ensuring appropriate documentation, and coordinating aftercare and transitions across the continuum of care. The role also contributes to process improvement, staff education, accurate recordkeeping, and communication with patients, families, clinical teams, admissions, payers, and patient financial services.

Requirements

Bachelor’s degree required.
Two years of previous work experience required; office or hospital setting preferred.
Computer skills, including word processing, spreadsheets, and data processing, required.
Knowledge of Joint Commission documentation and medical-record standards, and ability to maintain accurate records.
Current American Heart Association CPR certification or American Red Cross Professional Rescue certification required within 30 days of hire, with recertification every two years.
Formal training in management of the aggressive patient (S.A.F.E.) required within 60 days of hire, with annual recertification.

Nice To Haves

Bachelor’s degree in Behavioral Science or Human Services preferred.
Previous work experience in an office or hospital setting preferred.
Knowledge of managed care, Medicaid, and Medicare preferred.
Utilization review experience in a hospital, outpatient, or managed care setting preferred.
Case management experience in a hospital, outpatient, or managed care setting preferred.
Knowledge of the DSM, ICD-10, and medical, mental health, and chemical dependency diagnosis and treatment processes preferred.

Responsibilities

Coordinate and track patient care, acting as a liaison between Rogers Behavioral Health and third-party payers to advocate for medical-necessity authorization.
Provide utilization information to third-party payers and facilitate physician-to-physician reviews or expedited appeals.
Coordinate with third-party payers and non-Rogers providers to ensure aftercare is complete and appointments are scheduled.
Attend and participate in interdisciplinary treatment team meetings.
Review active medical records for required medical-necessity documentation and escalate documentation or quality-of-care issues as needed.
Communicate documentation quality concerns to utilization review, admitting, and clinical leadership, and collaborate on feedback, education, and training for clinical staff.
Initiate the physician advisory review process when needed.
Coordinate among admissions, clinical teams, payer strategies, and patient financial services to obtain medical-necessity authorization, single-case agreements, or self-pay deposits; inform UR leadership of sensitive cases or potential contractual arrangements.
Work with regulatory and quality departments to identify, investigate, or resolve issues that may put patients or Rogers Behavioral Health at risk.
Maintain a list of resources to use in accordance with best practice and follow established Standard Work and documentation timelines.
Lead discharge planning among patients, families, clinicians, outpatient providers, insurance case managers, county services, legal representatives, and other stakeholders.
Assess patient and support-system resource needs, including medication management, psychotherapy, ongoing medical care, housing or placement, finances, community support, and county-based support.
Begin discharge planning at admission by obtaining collateral input, securing required authorizations for release of information, and ensuring patient demographics are accurate across Rogers Behavioral Health and payer systems.
Collaborate with patients, families, and treatment teams throughout care to develop or adjust aftercare plans.
Complete aftercare plans before discharge, including scheduling appointments or arranging transfers to other Rogers programs.
Document discharge-planning activities in the electronic health record, arrange community resources, and provide documentation to other providers to support transitions of care.
Populate and maintain the referent/provider database in the electronic health record.
Support UR department process-improvement initiatives, assist new UR case management specialists and care advocates with Standard Work, help develop and implement new Standard Work, and assist with data collection for continuous improvement.
Provide professional communication and customer service to stakeholders, including ongoing case-status communication with clinical teams, admissions, and third-party UR and case management teams.
Assist patient financial services staff in investigating reimbursement problems.
Communicate with patients and families about aftercare planning, insurance benefits, authorizations, aftercare recommendations, self-pay arrangements, medical-necessity denials, and potential costs of care.