Utilization Review Case Manager

Job Description

Job Description

Utilization Review Case Manager

The UR Case Manager will complete prior authorizations and concurrent reviews for new admissions or existing patients. The UR Case Manger will work with insurance companies and the clinical team, reviewing documentation to determine medical necessity criteria and length of stay.

Responsibilities

• Obtain prior authorizations for all inpatient and IOP admissions based on established medical necessity criteria and documentation collected from the Electronic Health Record and clinical staff.
• Performs concurrent and step-down reviews for patients to ensure continuity of care and ensure extended stays are medically justified and documented in patient's medical records.
• Provides routine verbal, online and written documentation of the initial assessment and progress of the individual to the payer on a timely, regular basis.
• Participates in rounds as needed and collaborates with Attending Physician to evaluate and ensure diagnosis and documentation are appropriate for lengths of stay and continued-stay.
• Communicate with Patient Accounts, Treatment Team, and HIM for additional information, diagnosis confirmation and medical records requests.
• Prepare cases for Physician Review and appeals including scheduling and follow up with Unit Social Worker and Patient Accounts.
• Maintains communication with the Clinical Social Worker on the unit to facilitate timely discharge planning.
• Enter all documentation in EHR and / or spreadsheet and establish a tracking system to monitor for review due dates.
• Complete retrospective reviews as needed and submit letter and documentation for approval.
• Monitor and report to the Utilization Review Committee any cases that do not meet established guidelines for admission or continued stay.
• Identifies problems related to the quality of patient care and refers them to the Quality and Experience Team
• Utilizes the computer system for retrieval of information, documentation, and preparation of reports.
• Understands requirements for prior approval by payer and acquires data necessary to determine the cost of care and utilizes strategies to manage the length of stay and resource utilization within the case managed and patient populations and documents the results.
• Demonstrates the knowledge and skills necessary to provide care, based on physical, psychosocial, educational, safety, and related criteria, appropriate to the age of the patients served in an assigned area.
• Proactively review the daily activity to ensure account errors are minimized.
• Exhibits excellent organizational & communication skills.
• Performs other duties and responsibilities as assigned.

Required Skills / Abilities :

• Basic computer skills (Microsoft Office applications)
• Experience with electronic medical records.
• Must have the ability to function optimally in a stressful environment, and the ability to remain calm in emotionally charged situations.
• Residential LOC authorizations / concurrent reviews (Psych & SUD)
• Obtaining out of network authorizations for Psych & SUD Residential LOC
• LOCUS Criteria experience

Education and Experience :

Registered nurse with active Connecticut license and one-year psychiatric experience or Master Level Clinician with prior experience in Utilization review

Physical Requirements :

Ability to move light objects weighing less than 20 pounds for short distances.

Silver Hill Hospital ( SHH ) is fully committed to equal employment and advancement opportunities for all present employees as well as for applicants in all phases of the employment process (recruitment, hiring, assignment, conditions of employment, compensation, benefits, training, promotion, transfer, discipline, and termination).

Therefore, except in any cases of bona fide occupational qualification or need, SHH will act without regard to race, color, religion, national origin, age, sex, marital status, status as a protected veteran, sexual orientation, gender identity or expression, pregnancy, past / present history of mental disorder, intellectual disability, physical or learning disability, genetic information or any other characteristics protected by applicable law, (unless it is shown by supervisory personnel that a disability prevents performance of the work involved or may result in undue hardship) in all aspects of the employment process and relationship.

This policy is based on the understanding that an applicant can handle the job requirements. Employment decisions will be based on merit, qualifications, and abilities.