Utilization Review Case Manager - Partial Hospitalization Program

Luminis Health • Bowie, MD

8d • $81,967 - $122,951 • Onsite

About The Position

Performs and monitors integrated, concurrent utilization review and case referrals on patients, consistent with the approved Utilization Review Plans. Works with medical and professional staff to obtain appropriate clinical documentation for review and optimal patient placement. Maintains contact with Managed Care and other third party payors to assure appropriate case management.

Requirements

• BA/BS
• Two years of experience performing utilization review or utilization management.

Responsibilities

• Performs duties according to established standards for age groups adolescence through geriatric.
• Assesses data reflective of the patients status and interprets the appropriate information needed to identify each patients requirements relative to his or her age-specific needs. Maintains monthly statistical data and reports data to Clinical Director.
• Identifies status of physical, social and psychological needs of the patient, family and significant others.
• Evaluates data obtained in the bio-psychosocial and nursing history and assesses patients and their families to determine by interview, appropriateness for admission or referral.
• Determines the medical necessity and appropriateness of admission, using established criteria and standards.
• Verifies that pre-admission assessment is performed, and pre-authorizes patients as applicable.
• Monitors medical records for medical necessity and appropriateness of continued stay in accordance with established and approved norms.
• Verifies prior authorization data and performs concurrent reviews with external review agents on a daily basis in order to provide medical necessity and intensity of service information for continued stay approvals.
• Consolidates, tracks and reports performance on completed utilization review forms for all clinical areas and relays information to the multi-disciplinary treatment team.
• Resolves matters on outliers and initiates/follows up on appeals for determination at variance with program norm.

Benefits

• Medical, Dental, and Vision Insurance
• Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year)
• Paid Time Off
• Tuition Assistance Benefits
• Employee Referral Bonus Program
• Paid Holidays, Disability, and Life/AD&D for full-time employees
• Wellness Programs
• Employee Assistance Programs

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level