Utilization Review Case Manager

Position Summary:

The UR Case Manager will be responsible for managing an active caseload of clients at the following Levels of Care: Partial Hospitalization, and Intensive Outpatient.

S/he acts as a liaison between insurance companies, admissions, and clinical teams.

The UR Case Manager is responsible for gathering required information, effectively case-building, and collaborating with members of both the Utilization Review Team and interdisciplinary Treatment Team to ensure optimization of each client's coverage and benefits.

S/he is responsible for communicating updates to appropriate representatives at the insurance company, the Clinical Team, and as directed by the Manager/Director of Utilization Review.

Essential Job Functions:


* Complete Initial, concurrent, Peer, and retrospective reviews in a timely manner to ensure continuous coverage.


* ‪Utilize clinical information and knowledge of Medical Necessity criteria to effectively communicate plans of care to insurance case managers, facility staff, and healthcare partners.


* Conduct and manage initial, concurrent, and discharge reviews to optimize benefits and utilization.


* Represents the UR Department in a professional and positive way to other Departments and the company as a whole.


* Consistently demonstrate excellent communication, prioritization, and multi-tasking skills.


* ‪Maintains contact with the clients' families and keeps them updated on current insurance authorization updates, Peer Reviews, and Denials.


* Document all activities in a detailed manner in applicable CRM/EMR.


* ‪Collaborate with Clinicians and the multidisciplinary team to obtain necessary clinical documentation for reviews and ensure effective utilization of resources.


* ‪Participate in weekly Treatment Team and Continuing Care Meetings as appropriate.


* ‪Prepares and submit Appeal documentation (including rationales) to the appropriate entities as indicated


* Coordinate, schedule, and complete Peer-to-Peer and Appeal reviews.


* Complete weekly Treatment Team notes and provides updates to the Psychiatrist as requested by the Director/Manager.


* Track all data concerning current LOS and information pertaining to LOS, as well as discharge LOS and information pertaining to discharge LOS.


* Hold training to clinical staff and other individuals needed, concerning medical necessity, insurance requirements, as well as other areas needed that are directly affect by LOS


* Follow chain of command both within the Department and outside of the Department.

Core Competencies:


* Proficient in MS Office applications, which include Outlook, Word, Excel, and PowerPoint.


* Ability to build and sustain trusting relationships with diverse individuals and groups.


* Ability to maintain confidentiality of sensitive information and adhering to ethical standards.


* Actively offering assistance to team members when needed and celeb...