Utilization Review/Case Manager

Freedom Magnolia•Magnolia, MS

11d

About The Position

Freedom Behavioral Hospital of Magnolia is seeking a full-time Utilization Review/Case Manager to join its behavioral health team. The role ensures patients receive appropriate, medically necessary care while coordinating discharge planning and supporting reimbursement through effective utilization management. The position coordinates utilization management, insurance authorization, concurrent reviews, discharge planning, and continuity of care for patients admitted to the psychiatric hospital. It serves as a liaison among physicians, insurance companies, patients, families, and community providers to support appropriate levels of care, timely authorizations, and safe discharge planning.

Requirements

Minimum of two years of experience in behavioral health, case management, utilization review, or discharge planning.
Strong knowledge of behavioral health levels of care and medical necessity criteria.
Excellent communication and organizational skills.
Computer proficiency and experience with electronic medical records.

Nice To Haves

Behavioral health or psychiatric hospital experience.
Experience with Medicare, Medicaid, and commercial insurance authorizations.
Knowledge of InterQual® or MCG® medical necessity criteria.
Experience with utilization review and denial management.
Discharge planning and community resource coordination.

Responsibilities

Complete admission reviews and obtain insurance authorizations.
Perform concurrent reviews with commercial insurance, Medicare Advantage, Medicaid Managed Care, and other third-party payers.
Submit clinical documentation supporting medical necessity.
Coordinate peer-to-peer reviews when required.
Monitor authorization status and approved lengths of stay.
Manage denial prevention and appeal processes.
Maintain accurate utilization review documentation and track authorization dates, notifying providers of pending reviews.
Ensure compliance with payer guidelines and regulatory requirements.
Complete psychosocial and discharge planning assessments.
Coordinate interdisciplinary treatment planning and develop individualized discharge plans beginning at admission.
Arrange follow-up appointments with outpatient providers and coordinate referrals to appropriate programs, facilities, and community providers.
Arrange transportation for discharge when needed.
Collaborate with families and caregivers throughout hospitalization.
Coordinate transfers to higher or lower levels of care as appropriate.
Participate in daily treatment team meetings and collaborate with psychiatrists, nursing staff, therapists, social workers, and administration.
Communicate with insurance case managers and payer representatives.
Ensure continuity of care following discharge and facilitate patient and family meetings as needed.
Maintain complete, accurate, and timely documentation in the electronic medical record, including utilization reviews, discharge planning activities, payer communications, and records supporting medical necessity and reimbursement.
Ensure documentation meets CMS, Joint Commission, and Mississippi Department of Health requirements.
Maintain compliance with CMS Conditions of Participation, Joint Commission standards, HIPAA, Mississippi Department of Health regulations, and hospital policies and procedures.
Participate in quality improvement and survey readiness activities.