UR Case Management Specialist

Rogers Memorial Hospital•Oconomowoc, WI

23h

About The Position

The UR Case Management Specialist provides leadership in facilitating the treatment process from admission through discharge. The role monitors treatment and advocates for the best interests of patients, their families, and Rogers Behavioral Health while managing risk and supporting quality patient care and cost/quality outcomes. The specialist collaborates across departments to resolve care-delivery issues and serves as a liaison among Rogers Behavioral Health, patients and families, third-party payers, and external providers. The specialist coordinates utilization review and discharge planning, supports medical-necessity authorization and documentation, and helps ensure continuity of care after discharge. The role also contributes to department goals, regulatory compliance, staff education, customer service, and continuous process improvement. The position requires a bachelor's degree, at least two years of work experience, computer skills, and specified CPR and aggressive-patient-management training and certifications.

Requirements

Bachelor's degree required; a degree in Behavioral Science or Human Services is preferred.
At least 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 the ability to maintain accurate records.
Current American Heart Association CPR certification or American Red Cross Professional Rescue certification is required within 30 days of hire, with recertification every two years.
Formal training in management of the aggressive patient (S.A.F.E.) is required within 60 days of hire, with annual recertification.
Ability to work independently with minimal supervision.

Nice To Haves

Behavioral Science or Human Services bachelor's 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 diagnosis and treatment processes.

Responsibilities

Coordinate and track patient care and act 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 Rogers Behavioral Health, 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 concerns.
Communicate documentation-quality concerns with utilization review, admitting, and clinical leadership.
Collaborate with admitting and clinical leadership to provide feedback, education, and training on medical-necessity documentation.
Initiate the physician advisory review process when needed.
Coordinate between admissions, clinical teams, payer strategies, and patient financial services to secure authorizations, single-case agreements, or self-pay deposits.
Inform utilization review leadership of sensitive cases or cases that may involve payer strategies and contractual arrangements.
Work with regulatory or quality departments to identify, investigate, and resolve issues that could place patients or Rogers Behavioral Health at risk.
Maintain a list of resources for use in accordance with best practices.
Follow established Standard Work and meet documentation standards and deadlines.
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 needs involving medication management, psychotherapy, ongoing medical care, housing or placement, finances, community support, and county-based support.
Begin discharge planning at admission by obtaining collateral information, securing required releases 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 continuing-care plans.
Complete aftercare plans before discharge, including scheduling follow-up appointments or arranging transfers to other Rogers programs.
Document discharge-planning steps in the electronic health record, arrange community resources, and provide documentation needed by other providers for transitions of care.
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, identify waste and solutions, and help collect data for continuous improvement.
Provide professional communication and customer service to stakeholders and keep clinical teams, admissions, and payer utilization review and case-management teams informed about case status.
Assist patient financial services with 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.
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, such as Joint Commission and State of Wisconsin requirements.
Educate new staff about relevant regulations and requirements as directed, and participate in regulatory learning, in-services, seminars, meetings, committees, team projects, and education of other disciplines.
Demonstrate punctuality, preparedness, effective communication, organization, timely responses, professional conduct, and a positive, solution-focused approach to workplace concerns.
Attend outside seminars or educational classes to support professional growth and maintain a positive, professional attitude toward external stakeholders.
Comply with hospital policies and procedures, including Human Resources, Infection Control, and Employee Health policies and programs.
Wear appropriate professional attire and work independently with minimal supervision.
Perform other duties as assigned.