UR Case Management Specialist

Rogers Behavioral Health, Inc.; West Allis (WI); In loco; USD 60.000 - 90.000; Tempo pieno

Descrizione del lavoro

Rogers Behavioral Health, Inc. in Wisconsin is seeking a UR Case Management Specialist to lead care coordination from admission through discharge.

You will advocate for medical necessity with payors, support aftercare planning, and collaborate with clinical leadership to ensure high-quality, cost-efficient patient care. You will participate in interdisciplinary teams, review documentation for compliance, and drive process improvements within the utilization review department to enhance outcomes

Competenze

• Bachelor's Degree in Behavioral Science or Human Services is required.
• Two years of work experience in an office or hospital setting is required.
• Knowledge of managed care, Medicaid and Medicare is preferred.
• Utilization review experience in hospital, outpatient or managed care setting preferred.
• Case management experience in hospital, outpatient or managed care setting preferred
• Knowledge of the DSM, ICD-10, medical, mental health and chemical dependency diagnosis and treatment process is preferred.
• Computer skills are required, including word processing, spreadsheets and data processing.
• Knowledge of Joint Commission documentation and medical records standards and ability to maintain accurate records.
• Current American Heart Association CPR certification or American Red Cross Professional Rescue is required within 30 days of hire; bi-annual re-certification is required.
• Formal training in the management of the aggressive patient (S.A.F.E.) is required within 60 days of hire; annual re-certification is required.

Mansioni

• Coordinate and track patient care across the treatment continuum.
• Act as liaison between Rogers Behavioral Health and third-party payors for medical necessity authorization and peer-to-peer reviews.
• Ensure aftercare planning and discharge planning coordination with all stakeholders.
• Attend interdisciplinary treatment team meetings and provide documentation and feedback to clinical leadership.
• Review medical records to ensure documentation meets medical necessity requirements; elevate issues as needed.
• Collaborate with admissions, clinical teams, payer strategies and patient financial services to secure authorizations and single-case agreements.
• Identify and resolve issues that place patients or Rogers at risk; communicate with UR leadership and regulatory teams.
• Support process improvement initiatives within the UR department for continuous quality care.

Formazione

Bachelor's Degree (Behavioral Science or Human Services)

Two years of previous work experience (office or hospital setting)

Knowledge of managed care, Medicaid and Medicare

Utilization review experience in hospital/outpatient/managed care

Case management experience in hospital/outpatient/managed care

Strumenti

Word processing

Spreadsheets

Data processing

Descrizione del lavoro

The UR Case Management Specialist provides leadership in the facilitation of the treatment process from admission to discharge. The UR Case Management Specialist monitors the treatment process, acting on behalf of the best interest of the patients, their families, and Rogers Behavioral Health to manage risk, ensure quality patient care and cost/quality outcomes. The UR Case Management Specialist collaborates with other departments to resolve identified care delivery issues at Rogers Behavioral Health.

Job Duties & Responsibilities:

Coordinate and Track Patient Care

• Act as the liaison between RBH and third- party payors in advocating for medical necessity authorization Provide utilization information to third- party payors and facilitate any physician-to- physician (peer to peer) reviews or expedited appeals.
• Act as a liaison between RBH, third- party payers, and non-RBH providers to ensure aftercare is complete with appointments scheduled.
• Attend and participate in interdisciplinary treatment team meetings.
• Review active medical records to ensure medical necessity documentation requirements are met and elevate documentation or quality care issues if needed.
• Communicate with utilization review (UR) leadership, admitting leadership, and clinical leadership regarding the quality of documentation within the medical record.
• Collaborate with admitting and clinical leadership in providing feedback, education and training to clinical staff regarding medical necessity documentation.
• Initiate the physician advisory review process as needed.
• Provide leadership in the facilitation between Rogers programs by acting as the primary liaison between admissions, clinical teams, payer strategies and patient financial services to ensure medical necessity authorization, single-case agreements or self-pay deposits are obtained.
• Inform UR leadership of any sensitive cases or potential cases involving planner strategies that may lead to contractual arrangements.
• Work with regulatory and/or quality department to identify, investigate, or resolve issues that place patients or Rogers Behavioral Health at risk.
• Maintain a list of specific resources to be used in accordance with best practice.
• Adhere to established Standard Work and ensure all documentation standards are met within required time frame.

Provide leadership in aftercare planning for all patients by coordinating the discharge planning process between all stakeholders including, but not limited to, patients/families, Rogers' clinicians, outpatient providers, insurance case managers, county services, legal, etc. to establish discharge plans that meet the clinical needs of the patient.

• Assess patient/support system needs for resources based on medication management, psychotherapy, ongoing medical care, housing/placement concerns, financial needs, community support, and county-based support.
• Ensure the discharge planning process begins at admission by obtaining collateral input from the referral source and other treatment providers, obtaining necessary authorization for the release of patient information as required by Hospital policy and ensure patient demographics are accurate between RBH and third- party payer systems.
• Provide ongoing collaboration with the patient/familyand treatment team on continuing care needs to further develop or adjust the aftercare plan throughout the treatment process.
• Complete aftercare plans prior to discharge including scheduling aftercare appointments or arranging transfer to other Rogers' programs. Document all steps of the discharge planning process in the electronic health record.
• Arrange for community resources to facilitate discharge. Provide all needed documentation to other providers to facilitate successful transition through the continuum of care.
• Populate and maintain referent/provider database in the electronic health record.

Support process improvement initiatives within the UR department.

• Provide assistance to new UR case management specialists and care advocates with understanding and adhering to standard work.
• Assist in the creation and implementation of new standard work by identifying areas of waste and collaborating with others to identify solutions.
• Assist with the collection of data to facilitate continuous improvement.

Provide professional communication and customer service to all stakeholders.

• Provide ongoing communication with clinical teams, admissions, and third- party UR and case management teams about the status of cases.
• Assist patient financial services staff with the investigation of any reimbursement problems.
• Communicate with patients and/or family members concerning aftercare planning, insurance benefits, authorizations, aftercare recommendations, self-pay arrangements, and/or medical necessity denials from third- party payors for continued stays.
• Educate patients and family members regarding any costs of care that may occur in the course of treatment.

Promote department goals as well as the mission of Rogers Behavioral Health.

• Communicate goals to fellow staff members.
• Demonstrate measurable goal achievement.
• Maintain department policies and procedures.
• Include requirements and guidelines from external agencies (eg. Joint Commission, State of Wisconsin).
• Educate new staff regarding regulations or requirements of those functions that relate to their areas or departments, as directed.

Demonstrate understanding of Joint Commission and other regulatory agency compliance regulations.

• Involve self in the learning and application of standards relevant to the Admission Services department.
• Participate in in-services, seminars, and other meetings to increase involvement and awareness of regulations.
• Involve self in the education of other disciplines regarding the department's regulations.

Additional Job Description:

Education/Training Requirements:

• Bachelor's Degree is required; Behavioral Science or Human Services is preferred.
• Two (2) years previous work experience required, office or hospital setting preferred.
• Knowledge of managed care, Medicaid and Medicare is preferred.
• Utilization review experience in a hospital, outpatient or managed care setting preferred.
• Case management experience in a hospital, outpatient or managed care setting preferred
• Knowledge of the DSM, ICD-10, medical, mental health and chemical dependency diagnosis and treatment process is preferred.
• Computer skills are required, including word processing, spread sheets and data processing.
• Knowledge of Joint Commission documentation and medical records standards and ability to maintain accurate records.
• Current American Heart Association CPR certification or American Red Cross Professional Rescue is required within thirty (30) days of date of hire. Bi-annual re-certification is required.
• Formal training in the management of the aggressive patient (S.A.F.E.) is required within sixty (60) days of date of hire. Annual re-certification is required.

With a career at Rogers, you can look forward to a Total Rewards package of benefits, including:

• Health, dental, and vision insurance coverage for you and your family
• 401(k) retirement plan
• Employee share program
• Life/disability insurance
• Flex spending accounts
• Tuition reimbursement
• Health and wellness program
• Employee assistance program (EAP)

Through UnitedHealthcare, UMR and HealthSCOPE Benefits creates and publishes the Machine-Readable Files on behalf of Rogers Behavioral Health. To link to the Machine-Readable Files, please visit Transparency in Coverage (uhc.com)