UR Case Management Specialist

Rogers Memorial Hospital•Oconomowoc, WI

About The Position

The UR Case Management Specialist leads and facilitates the treatment process from admission through discharge. The role monitors treatment, advocates for patients and families, and supports Rogers Behavioral Health in managing risk, ensuring quality care, and achieving cost and quality outcomes. The specialist collaborates across departments to address care-delivery issues and serves as a liaison among Rogers programs, patients and families, providers, and third-party payers. The position coordinates medical-necessity reviews and authorizations, supports appeals and physician-to-physician reviews, monitors clinical documentation, and communicates documentation or quality concerns to appropriate leaders. It also leads discharge and aftercare planning by coordinating stakeholders, arranging appointments and community resources, documenting the process in the electronic health record, and supporting transitions across the continuum of care. The specialist contributes to utilization review process improvement, helps colleagues understand standard work, communicates with patients and families about aftercare and financial matters, and supports compliance with department policies and applicable regulatory requirements. A bachelor’s degree and two years of previous work experience are required. Current CPR certification and formal S.A.F.E. training are required within specified periods after hire, with recertification requirements.

Requirements

Bachelor’s degree required; a degree in Behavioral Science or Human Services is preferred.
Two years of previous work experience required; office or hospital experience is preferred.
Computer skills, including word processing, spreadsheets, and data processing, are 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.
Demonstrated understanding of Joint Commission and other regulatory agency compliance regulations.

Nice To Haves

Behavioral Science or Human Services degree.
Office or hospital work experience.
Knowledge of managed care, Medicaid, and Medicare.
Utilization review experience in a hospital, outpatient, or managed-care setting.
Case management experience in a hospital, outpatient, or managed-care setting.
Knowledge of the DSM, ICD-10, and medical, mental health, and chemical-dependency diagnoses and treatment processes.

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 and expedited appeals.
Coordinate with third-party payers and non-Rogers providers to ensure aftercare is arranged and appointments are scheduled.
Attend and participate in interdisciplinary treatment team meetings.
Review active medical records for medical-necessity documentation and escalate documentation or quality-of-care issues when needed.
Communicate documentation quality concerns with utilization review, admitting, and clinical leadership.
Collaborate with admitting and clinical leadership to provide clinical staff with feedback, education, and training on medical-necessity documentation.
Initiate physician advisory reviews as needed.
Coordinate among admissions, clinical teams, payer strategies, and patient financial services to obtain authorizations, single-case agreements, or self-pay deposits.
Inform utilization review leadership about sensitive cases and potential payer-strategy cases that may lead to contractual arrangements.
Work with regulatory and quality departments to identify, investigate, or resolve issues that put patients or Rogers Behavioral Health at risk.
Maintain a list of resources for use in accordance with best practice; follow established standard work and documentation time frames.
Lead aftercare planning by coordinating discharge planning among patients and 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 gathering collateral input, obtaining required releases of information, and ensuring demographic information is accurate across Rogers and payer systems.
Collaborate with patients, families, and treatment teams throughout care to develop or adjust continuing-care plans.
Complete aftercare plans before discharge, including scheduling appointments or arranging transfer to other Rogers programs.
Document discharge-planning steps in the electronic health record and arrange community resources and documentation needed for successful transitions.
Populate and maintain the referent/provider database in the electronic health record.
Support utilization review process-improvement initiatives, assist new specialists and care advocates with standard work, help develop new standard work, identify waste, and collect data for continuous improvement.
Provide professional communication and customer service; keep clinical teams, admissions, third-party utilization review teams, and case management teams informed about case status.
Assist patient financial services with reimbursement investigations and communicate with patients and families about aftercare, insurance benefits, authorizations, recommendations, self-pay arrangements, denials, and potential care costs.
Promote department goals and the Rogers Behavioral Health mission, communicate goals to colleagues, and demonstrate measurable goal achievement.
Maintain department policies and procedures, including applicable external agency requirements and guidelines.
Educate new staff about relevant regulations and requirements as directed; understand and apply Joint Commission and other regulatory compliance standards.
Participate in in-services, seminars, meetings, and education of other disciplines to increase awareness of relevant regulations.