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 with other departments to address care-delivery issues and serves as a liaison among patients and families, clinical and admissions teams, third-party payers, and community providers. The specialist coordinates utilization review and medical-necessity authorization, reviews medical records and documentation, supports discharge and aftercare planning, and communicates with stakeholders about case status, insurance benefits, authorizations, and costs. The position also contributes to department operations, regulatory compliance, staff education, and continuous process improvement. A bachelor’s degree is required, with a behavioral science or human services degree preferred. Two years of prior work experience is required. Current CPR certification and formal training in management of the aggressive patient (S.A.F.E.) must be completed within the stated periods after hire.

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, 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; recertification required every two years.
Formal training in management of the aggressive patient (S.A.F.E.) required within 60 days of hire; annual recertification required.

Nice To Haves

Bachelor’s degree in behavioral science or human services preferred.
Office or hospital setting experience 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 DSM, ICD-10, and medical, mental-health, and chemical-dependency diagnosis and treatment processes preferred.

Responsibilities

Coordinate and track patient care, including advocating with third-party payers for medical-necessity authorization and facilitating peer-to-peer reviews or expedited appeals.
Liaise with Rogers Behavioral Health, third-party payers, and non-Rogers providers to support complete aftercare and scheduled appointments.
Attend and participate in interdisciplinary treatment team meetings.
Review active medical records for medical-necessity documentation and escalate documentation or quality-of-care concerns as needed.
Communicate documentation quality concerns with UR, admitting, and clinical leadership; collaborate with leaders to educate and train clinical staff on medical-necessity documentation.
Initiate physician advisory reviews when 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 about sensitive cases or potential cases that may involve payer-strategy contractual arrangements.
Work with regulatory or quality departments to identify, investigate, or resolve issues that may 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 discharge and aftercare planning among patients, families, clinicians, outpatient providers, insurance case managers, county services, legal stakeholders, and others.
Assess patient and support-system resource needs, including medication management, psychotherapy, 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 in 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, 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 transitions through 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 with Standard Work, and help create and implement new Standard Work.
Identify waste, collaborate on solutions, and assist with collecting data for continuous improvement.
Provide professional communication and customer service to stakeholders and ongoing case-status communication with clinical teams, admissions, and third-party UR and case-management teams.
Assist patient financial services with reimbursement-problem investigations.
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 Rogers Behavioral Health’s mission, communicate goals to colleagues, demonstrate measurable goal achievement, and maintain department policies and procedures.
Apply external agency requirements and guidelines, including Joint Commission and State of Wisconsin requirements; educate staff as directed and demonstrate understanding of regulatory compliance.
Learn and apply standards relevant to the Admission Services department, participate in regulatory in-services and meetings, and educate other disciplines about departmental regulations.