UR Case Management Specialist

Rogers Behavioral Health•Oconomowoc, WI

About The Position

The UR Case Management Specialist provides leadership in facilitating the treatment process from admission through discharge. The specialist monitors treatment on behalf of patients, their families, and Rogers Behavioral Health to manage risk and support 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 medical necessity authorization, reviews records for documentation requirements, escalates quality or documentation issues, and supports clinical staff through feedback and education. The role also leads aftercare and discharge planning, coordinating stakeholders and resources to develop plans that meet patients’ clinical and support needs. Additional responsibilities include maintaining electronic health record information, supporting process improvement and standard work, assisting colleagues, communicating with stakeholders, and helping investigate reimbursement issues.

Requirements

Bachelor’s degree required.
Two years of previous work experience required.
Computer skills, including word processing, spreadsheets, and data processing, are required.
Knowledge of Joint Commission documentation and medical records 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, including 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 medical necessity documentation and escalate documentation or quality care issues as needed.
Communicate with UR, admitting, and clinical leadership about medical record documentation quality.
Collaborate with admitting and clinical leadership to provide clinical staff feedback, education, and training on medical necessity documentation.
Initiate the physician advisory review process as 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 about sensitive cases or potential payer-strategy cases that could lead to contractual arrangements.
Work with regulatory or 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 meet documentation standards and timelines.
Lead aftercare planning by coordinating discharge planning among patients and families, Rogers clinicians, outpatient providers, insurance case managers, county services, legal representatives, and other stakeholders.
Assess patient and support-system needs relating to 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 necessary releases of information, and ensuring patient demographics are accurate across Rogers Behavioral Health and payer systems.
Collaborate with patients, families, and the treatment team on continuing-care needs and adjust aftercare plans throughout treatment.
Complete aftercare plans before discharge, schedule follow-up appointments or arrange transfers to other Rogers programs, and document discharge-planning steps in the electronic health record.
Arrange community resources and provide documentation needed by other providers to support transitions across the continuum 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 in understanding and following Standard Work.
Help create and implement new Standard Work by identifying waste and collaborating on solutions.
Assist with collecting data for continuous improvement.
Provide professional communication and customer service to stakeholders.
Communicate case status to 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, recommendations, self-pay arrangements, and medical necessity denials for continued stays.
Educate patients and families about potential costs of care during treatment.