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 role monitors treatment on behalf of patients, their families, and Rogers Behavioral Health to manage risk, support quality patient care, and achieve cost and quality outcomes. The specialist collaborates with other departments to address identified care-delivery issues and serves as a liaison among Rogers programs, patients and families, clinical and admissions teams, third-party payers, and external providers. The position supports medical-necessity authorization and documentation, payer reviews and appeals, discharge and aftercare planning, and coordination of resources and transitions across the continuum of care. It also contributes to departmental process improvement, staff education, regulatory compliance, and ongoing communication with stakeholders. The specialist works independently with minimal supervision and performs other duties as assigned.

Requirements

Bachelor’s degree required.
Two years of previous work experience required.
Computer skills, including word processing, spreadsheets, and data processing, required.
Knowledge of Joint Commission documentation and medical-record standards, with the 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 the 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 from admission through discharge.
Liaise with third-party payers to advocate for medical-necessity authorization, provide utilization information, and facilitate peer-to-peer reviews or expedited appeals.
Coordinate with external providers and payers 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.
Communicate documentation quality concerns with UR, admitting, and clinical leadership; collaborate on feedback, education, and training for clinical staff.
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 UR leadership of sensitive cases or potential payer-strategy cases that may involve contractual arrangements.
Work with regulatory and quality departments to identify, investigate, or resolve issues that put patients or Rogers Behavioral Health at risk.
Maintain resources for use in accordance with best practice and comply with Standard Work and documentation timelines.
Lead aftercare planning by coordinating discharge planning among patients, families, Rogers clinicians, outpatient providers, insurance case managers, county services, legal stakeholders, and others.
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 releases of information, and ensuring patient demographics are accurate in Rogers and payer systems.
Collaborate throughout treatment with patients, families, and treatment teams to develop or adjust continuing-care plans.
Complete aftercare plans before discharge, schedule 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 to support successful transitions of care.
Populate and maintain the referent/provider database in the electronic health record.
Support UR process-improvement initiatives, assist new UR case management specialists and care advocates with Standard Work, and help create and implement new Standard Work.
Identify waste, collaborate on solutions, and assist with data collection for continuous improvement.
Provide professional communication and customer service to stakeholders, and communicate case status to clinical, admissions, payer UR, and case-management teams.
Assist patient financial services staff in investigating reimbursement problems.
Communicate with patients and families about aftercare, insurance benefits, authorizations, recommendations, self-pay arrangements, and medical-necessity denials; educate them about potential costs of care.
Promote department goals and Rogers Behavioral Health’s mission, communicate goals to colleagues, and demonstrate measurable goal achievement.
Maintain department policies and procedures and incorporate applicable external-agency requirements, including Joint Commission and State of Wisconsin requirements.
Educate new staff about relevant regulations and requirements as directed; understand and apply regulatory compliance standards and participate in related learning and education.
Participate in in-services, seminars, meetings, committees, team meetings, and projects as directed to increase regulatory awareness and professional involvement.
Demonstrate punctuality, preparedness, effective communication, organization, timely responses, professionalism, and a positive, solution-focused approach.
Address peer concerns calmly and constructively, communicate concerns and solutions, and maintain a professional attitude toward external parties.
Attend outside seminars or educational classes to support professional growth.
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.