Utilization Review Case Manager

A BETTER LIFE RECOVERY LLC•San Juan Capistrano, CA

2d•$30 - $35•Onsite

About The Position

The Utilization Review (UR) Case Manager serves as a key member of the interdisciplinary team and actively manages and directs insurance utilization throughout a client’s treatment episode, from admission to discharge while working with several departments including Admissions, Billing, Compliance, and Clinical, and plays an active role in treatment team discussions. The UR Case Manager acts as a liaison between insurance and facility/clinical teams while coordinating with discharge planners on estimated step down or discharge dates and insurance recommendations. UR Case Managers are responsible for their own assigned caseload including initial, concurrent, and discharge reviews, peer reviews, and expedited appeals and will oversee the effective coordination of services and manage issues in the following areas: admission and discharge, team conferences and plan of care communication, patient and family education when necessary, and payor relations.

Requirements

Must be 18 years or older to apply for this position.
Ability to pass a standard background check.
High School Diploma or equivalent.
At least 6 months experience working in the behavioral health or substance abuse field, with knowledge of general medical necessity and insurance criteria.
Ability to work on a computer/keyboard, type a minimum of 40 words per minute, use electronic systems, communicate with others through written and verbal formats, ability to sit for long periods of time, listening, reading comprehension, lifting up to 10 lbs.
Excel at both written and verbal communications to convey essential information; must be able to utilize the proper linguistic syntax and spelling.
Ability to use computer software including Microsoft Office, Adobe Acrobat, and G Suite products.
Knowledge of clinical and medical terminology as it relates to the delivery of clinical care to the clients within our programs.
Ability to operate standard office machines and equipment, including telephones, computers, copy machines, fax machines, calculators, scanners, and shredders.
Ability to be professional and maintain a positive attitude and relationships with coworkers.
Ability to communicate with people outside the organization, representing the organization to customers, the public, government, and other external sources.

Responsibilities

Timely and effective management of the individual caseload to include all assigned initial, concurrent, and discharge reviews.
Effectively communicate any deficiencies in chart/clinical documentation to the clinical team to ensure documentation is aligned with insurance company guidelines and standards.
Engage in strong advocacy for clients utilizing insurance, ensuring optimal length of stay.
Exemplify time management skills by scheduling peer reviews and appeals with available licensed providers as soon as possible, to minimize risk of uncovered days and/or lack of claim reimbursement.
Collaborate with the Director of Utilization Review and UR team on changes to LOC, authorization status, and complicated or time sensitive cases to better ensure optimal outcomes.
Keep accurate organizational notes and records for all actions completed related to the assigned caseload throughout all applicable spreadsheets.
Engage in any and all assigned training by the Director of Utilization Review to sharpen skill set, and increase knowledge of behavioral health utilization review.
Effectively relay any information shared by insurance care managers for collaboration of care to the appropriate AMFM clinical team.
Collaborate with the discharge planning team and clinical case managers by relaying any insurance information necessary to ensure a smooth and appropriate discharge plan for the individual assigned caseload.
Demonstrate a professional attitude and support the objectives of the facility philosophy through internal and external communications and interactions with all levels of staff, patients, community and referral sources.