Utilization Management (UM) Case Mgr

UHS•Auburn Hills, MI

3d•Onsite

About The Position

HAVENWYCK HOSPITAL (a UHS facility) Havenwyck Hospital is a Joint Commission-accredited and licensed psychiatric hospital, overlooking Lake Galloway in Auburn Hills, Michigan. We specialize in providing comprehensive, compassionate behavioral health services to children, adolescents and adults. It is the ultimate goal of our dedicated staff to build strength, confidence and knowledge within each patient, in hopes that they may continue learning and understanding their needs and practicing self-care for the rest of their lives. If you would like to learn more about this position before applying, please contact Havenwyck Hospital at 248-373-9200. POSITION SUMMARY: The Utilization Management Coordinator has responsibility for organizing and conducting the managed care process. These duties shall be directed toward supporting the hospital's mission in the pursuit of excellence in care/service and will include (but not limited to): conducting timely admission and continued stay record reviews with external payers, utilizing approved criteria to make determinations of medical necessity and level of care planning, verifying active treatment by completing internal audit reviews within approved time frames, assisting the treatment team when indicated in the discharge planning process, and acting as liaison with MD/Clinical Treatment Team and external agencies. Report authorizations, denials, and documentation concerns, as well as collaborate effectively across departments to minimize denials/faciliate optimal use of hospital resources. Through experience and knowledge, reports to external insurance and review entities an accurate presentation of the medical management of a patient’s illness, length of stay and care alternatives available within the confines on the client’s benefits and financial resources. Communicates with physicians, nursing staff, social workers and treatment team members as necessary to clarify patient’s clinical status and continued stay or discharge. Conducts phone, online and fax reviews with managed care providers and relays clinical data in a professional, assertive, clear and organized manner. Maintains a positive rapport with managed care providers; acts as a representative of Havenwyck Hospital. Communicates results of reviews with physicians and team via direct contact, phone calls and chart stickers. Communicates specific criteria and special requirement of managed care regarding discharge planning, family sessions, and treatment plans. Refers cases to the Physician Advisor/designee. Informs physician of need to contact the managed care reviewers and follows up to ensure call is made and ascertain the number of days obtained. Keeps accurate record of days assigned to patients and when the next review is necessary. Keeps accurate accounting of authorized days from admission to discharge. Monitors and tracks the certification and re-certification process for Medicare patients to make certain all state and federal reporting guidelines are met. Maintains a flow of information by documenting any information necessary to follow up on a case. Ensures accurate documentation of authorization status. Reviews cases on a daily basis, checking for discharges and day hospital admission and relaying pertinent information Acts as a facilitator for the provider, payor and patient in utilizing benefits in the most efficient and effectual manner. Has a working knowledge of insurance verification and benefits. Possess clinical skills including specific knowledge of diagnosis and dynamics involved in the treatment of psychiatric illnesses for patients of all ages.

Requirements

Bachelor Degree in social work, psychology, counseling or nursing required.
Limited or fully licensed (LBSW, RN, LLMSW, LLP, TLLP, LPC, LMFT, etc.).
A minimum of 2 years of post-graduate related experience in psychiatric or substance abuse treatment required.
Hospital utilization review/utilization management experience preferred.
Familiarity with manager health care process, medical terminology, experience in case management, discharge planning, and/or utilization review preferred.

Nice To Haves

Master's degree in social work, psychology, or counseling preferred.
Hospital utilization review/utilization management experience preferred.
Familiarity with manager health care process, medical terminology, experience in case management, discharge planning, and/or utilization review preferred.

Responsibilities

Conducting timely admission and continued stay record reviews with external payers
Utilizing approved criteria to make determinations of medical necessity and level of care planning
Verifying active treatment by completing internal audit reviews within approved time frames
Assisting the treatment team when indicated in the discharge planning process
Acting as liaison with MD/Clinical Treatment Team and external agencies
Report authorizations, denials, and documentation concerns
Collaborate effectively across departments to minimize denials/faciliate optimal use of hospital resources
Reports to external insurance and review entities an accurate presentation of the medical management of a patient’s illness, length of stay and care alternatives available within the confines on the client’s benefits and financial resources
Communicates with physicians, nursing staff, social workers and treatment team members as necessary to clarify patient’s clinical status and continued stay or discharge
Conducts phone, online and fax reviews with managed care providers and relays clinical data in a professional, assertive, clear and organized manner
Maintains a positive rapport with managed care providers; acts as a representative of Havenwyck Hospital
Communicates results of reviews with physicians and team via direct contact, phone calls and chart stickers
Communicates specific criteria and special requirement of managed care regarding discharge planning, family sessions, and treatment plans
Refers cases to the Physician Advisor/designee
Informs physician of need to contact the managed care reviewers and follows up to ensure call is made and ascertain the number of days obtained
Keeps accurate record of days assigned to patients and when the next review is necessary
Keeps accurate accounting of authorized days from admission to discharge
Monitors and tracks the certification and re-certification process for Medicare patients to make certain all state and federal reporting guidelines are met
Maintains a flow of information by documenting any information necessary to follow up on a case
Ensures accurate documentation of authorization status
Reviews cases on a daily basis, checking for discharges and day hospital admission and relaying pertinent information
Acts as a facilitator for the provider, payor and patient in utilizing benefits in the most efficient and effectual manner
Has a working knowledge of insurance verification and benefits
Possess clinical skills including specific knowledge of diagnosis and dynamics involved in the treatment of psychiatric illnesses for patients of all ages