Utilization Case Manager

The Case Manager coordinates with the admission staff and clinical staff to facilitate the meeting of patient's treatment needs as well as management of utilization review activities for the inpatient programs in accordance with the Joint Commission, Federal and State regulations, Oceans' mission, policies and procedures and Performance Improvement standards.
Acts as patient liaison for physician, clinical staff and family member's activities.
Works in coordination with the Performance Improvement Coordinator to conducts closed and concurrent reviews of medical records.
Interacts with members of the medical/clinical team to provide a flow of communication, ensure criteria for admission and continued stay are met and that the medical record documentation supports the level and intensity of service rendered as well as facilitating timely discharge planning.
Works with the primary therapist and nursing staff to facilitate treatment planning documentation, family contact, scheduling appointments, absentees from programming and access to community resources.
Essential Functions: Functions as patient liaison in the role of case manager to coordinate patient treatments with the physician, therapist and nursing staff.
Compiles psychosocial data and scribes on form; completes integration of assessment and presents to multi-disciplinary treatment team for review and approval; Schedules appointments, follows up on absentees and completes continuing care plans.
Attends treatment team meetings and communicates case management activities to the other team members.
Identifies and reports appropriate use under-use, overuse and inefficient use of services and resources to ensure high quality patient care is provided in the least restrictive environment and in a cost-effective manner.
Conducts review, when needed, of records in a timely manner to (1) determine appropriateness and clinical necessity of admissions, continued stay, and/or rehabilitation, and discharge; (2) determine timeliness of assessments and evaluations; i.
e.
, H&Ps, psychiatric evaluations, CIA formulation and discharge summaries; and (3) identify any under-, over- and/or inefficient use of services or resource.
Notifies appropriate staff members of any deficiencies noted so corrective actions can be taken in a timely manner; submits monthly report to PI Coordinator of findings and actions recommended to correct identified problems.
Coordinates flow of communication between physician/staff and third-party payers concerning reimbursement requisites.
Attends status meetings to communicate third party payer status, update attendance calendar and communicate individual patient needs to clinical and admission staff.
Shares pertinent data.
Initiates and completes appeals process for reimbursement denials; notifies inpatients of denials received; notifies physicians/staff/patients of reimbursement issues.
Upon notification by business office that potential exists to be included on a new managed care contract, makes contact with the managed care company and coordinates communications between administrator and the managed care company to obtain contractual arrangements.
Maintains coordination of information requests from third party payers for annual renewal or update of existing contracts.
Communicates to staff status of new/existing contracts.
Performs additional case management duties as required and coordinates flow of communication amend staff involved in the patient's care; completes paperwork for judicial commitments and state bed packets.
Completes referral process and necessary paperwork for all other levels of care and make follow-up appointments; including follow-up letters needed by the patient; completes all medication assistance forms and assists patients and families with follow-up care items.
Conducts special retrospective studies/audits when need is determined by M&PS and /or other committee structure.
Accurately does discharge reviews on 100% of all discharges per month; accurately inputs discharge review information into computer database; accurately send records for appeal in timely manner; accurately completes all initial CQI+ forms and questionnaires in a timely manner.
Performs other duties and projects as assigned.
Requirements Associate degree with emphasis on healthcare or bachelor’s degree in social services field preferred.
At least one year psychiatric/chemical dependency experience with good working psychiatric/medical knowledge.
Must have excellent assertive communication skills.
Knowledge and in-depth understanding of CD/psych treatment and discharge planning process.
Must have good writing and composition skills.
Must have good understanding of regulatory and fiscal reimbursement and utilization review as a primary component of patient care.
Must demonstrate strong patient advocacy skills.
Must be able to organize and prioritize high volume workload.
Must be able to analyze and utilize data and systems to provide individualized quality treatment in a cost-effective manner.
Must be able to function with minimal supervision.
Therapeutic Intervention De-escalation Education required.
Must have ability to maintain overall good work attitude and interact cooperatively and professionally with other staff members and third-party payers to achieve mutually beneficial outcome.
Must possess basic competency in age/disability/cultural diversity needs of patients served and ability to relate to patients in a manner sensitive to those needs.
Must successfully complete CPR certification and an Oceans approved behavioral health de-escalation program.
Subject to many interruptions.
Occasional pressure due to multiple calls and inquiries.
This position can be high paced and stressful; must be able to cope mentally and physically to atmosphere.
This person might sometimes experience disagreeable odors, sights and/or unpredictable patient behavior.
Work requires spending approximately 90% or more of the time inside a building that offers protection from weather conditions but not necessarily from temperature changes.