Utilization Review/Case Manager

Freedom Magnolia•Magnolia, MS

About The Position

Freedom Behavioral Hospital of Magnolia is hiring a full-time Utilization Review/Case Manager to support its behavioral health team. The role 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. The position includes completing admission and concurrent insurance reviews, submitting documentation to support medical necessity, coordinating peer-to-peer reviews, tracking authorizations, and managing denial prevention and appeals. It also involves psychosocial and discharge planning assessments, interdisciplinary treatment planning, referrals and follow-up arrangements, transportation coordination, and communication with patients' families and caregivers. The Utilization Review/Case Manager participates in daily treatment team meetings, maintains accurate and timely electronic medical record documentation, and supports continuity of care after discharge. The role requires compliance with payer guidelines, CMS Conditions of Participation, Joint Commission standards, HIPAA, Mississippi Department of Health regulations, and hospital policies. The position also participates in quality improvement and survey readiness activities.

Requirements

At least 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.
Coordinate referrals to IOPs, PHPs, community mental health centers, primary care providers, nursing facilities, assisted living facilities, home health agencies, and substance use treatment programs.
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.
Document utilization reviews, discharge planning activities, and communications with payers; maintain 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.