Utilization Review Case Manager - Partial Hospitalization Program

Luminis Health, Inc.; Annapolis (MD); On-site; USD 82,000 - 123,000; Full time

Benefits offered by this job

Medical, Dental, Vision

Retirement Plan with employer match

Paid Time Off

Tuition Assistance

Employee Referral Bonus

Paid Holidays and Disability

Wellness Programs

Employee Assistance Programs

Job summary

Luminis Health in Lanham, MD is seeking a Utilization Review/Case Manager for the Partial Hospitalization Program. The role performs integrated utilization review and coordinates referrals, working with medical staff to gather documentation and determine medical necessity for admission and placement.

Requirements include a BA/BS and at least two years in utilization review or utilization management. The position involves pre-authorizations, concurrent reviews with external reviewers, and

Qualifications

• BA/BS degree required.
• Two years of utilization review or utilization management experience preferred.
• Ability to coordinate with medical staff and payors.

Responsibilities

• Performs and monitors integrated utilization review and case referrals on patients.
• Obtains appropriate clinical documentation for review and optimal patient placement.
• Maintains contact with Managed Care and other third party payors for approval and placement.
• Pre-authorizes patients and conducts concurrent reviews with external review agents.
• Consolidates, tracks and reports performance on utilization review forms for all clinical areas.

Skills

Utilization review

Case management

Communication

Education

BA/BS Degree

Job description

Luminis Health

Title: Utilization Review/Case Manager-Partial Hospitalization Program

Department: Lanham Partial Hospitalization

Reports To: Director- Clinical Director Behavioral Health Lanham

Cost Center/Job Code: 41000-42002-001148

FLSA Status: Exempt

Position Objective

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.

Essential Job Duties

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

1. Performs duties according to established standards for age groups adolescence through geriatric.
2. 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.
3. Identifies status of physical, social and psychological needs of the patient, family and significant others.
4. 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.
5. Determines the medical necessity and appropriateness of admission, using established criteria and standards.
6. Verifies that pre-admission assessment is performed, and pre-authorizes patients as applicable.
7. Monitors medical records for medical necessity and appropriateness of continued stay in accordance with established and approved norms.
8. 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.
9. Consolidates, tracks and reports performance on completed utilization review forms for all clinical areas and relays information to the multi-disciplinary treatment team.
10. Resolves matters on outliers and initiates/follows up on appeals for determination at variance with program norm.

Educational/Experience Requirements

• BA/BS Degree, required
• Two years of experience performing utilization review or utilization management, preferred.

Working Conditions, Equipment, Physical Demands

There is a reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.

Physical Demands -

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.

Pay Range

$81,967.12—$122,950.68 USD

Luminis Health Benefits Overview

• 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 and more
• *Benefit offerings based on employment status