Care Advocate

About the role

The Care Advocate provides leadership in facilitating the treatment process from prior to admission to discharge. The Care Advocate monitors the treatment process of both individual and aggregate cases, acting on behalf of the best interest of patients, their families, and Rogers Behavioral Health to manage risk, ensure quality patient care, and achieve cost-quality outcomes. This role crosses departmental boundaries to address and resolve identified care delivery problems.

Responsibilities

• Act as the liaison between Rogers Behavioral Health (RBH) and third-party payers to advocate for initial (pre-certification) and ongoing medical necessity authorization (concurrent reviews).
• Provide utilization information to third-party payors and facilitate physician-to-physician (peer-to-peer) reviews or expedited appeals.
• Review active medical records to ensure medical necessity documentation requirements are met; escalate documentation or quality care issues as needed.
• Communicate with utilization review (UR), admitting, and clinical leadership regarding the quality of documentation within the medical record.
• Collaborate with admitting and clinical leadership to provide education and training to clinical staff on medical necessity documentation.
• Provide documentation training and feedback to clinical and admitting staff on the quality of documentation.
• Meet collaboratively with clinicians and/or admissions staff to facilitate their knowledge of documentation issues, medical necessity, and/or admission criteria.
• Initiate the physician advisory review process as required.
• Ensure coverage for all Rogers transitions of care to internal treatment programs by acting as the liaison between admissions, clinical teams, managed care, and patient financial services to secure medical necessity authorization, single-case agreements, or self-pay deposits.
• Inform UR leadership of sensitive cases or potential cases involving managed care that may lead to contractual arrangements.
• Work with regulatory and/or quality departments to identify, investigate, or resolve issues that place patients or Rogers Behavioral Health at risk.
• Serve in one of the following primary responsibility areas, with the ability to function across all areas:
  • Pre-certifications/Admissions:
    • Ensure all patients admitted to RBH have a current screening per admitting standard work that documents medical necessity.
    • Complete all initial authorization requests with third-party payers.
    • Review all new admissions to identify potential coverage concerns for both current admission and discharge planning.
    • Resolve or escalate any concerns present on admission to manage risk and ensure quality patient care and cost-quality outcomes.
  • Programs:
    • Lead the multi-disciplinary treatment team in ensuring all patients receive quality care with positive cost/quality outcomes.
    • Complete all concurrent reviews with third-party payers.
    • Develop working relationships with clinical staff, particularly physicians and managers, to ensure open communication regarding treatment and case management issues.
    • Monitor discharge plans to ensure accuracy and completion, including appointment dates, times, and addresses of providers.
    • Collaborate with treatment teams and managed care in coordinating discharge plans requiring a single-case agreement prior to admission to the next level of care.
  • Float:
    • Provide coverage for other care advocates whose primary responsibilities are pre-certification/admission or programs.
    • Support process improvement initiatives within the UR department.
    • Assist new care advocates with understanding and adhering to standard work.
    • Identify areas of waste and collaborate with others to develop solutions for new standard work.
    • Assist with data collection to facilitate continuous improvement.
• Provide communication and customer service to all stakeholders, including:
  • Ongoing communication with clinical teams and admissions/Patient Access about case status.
  • Assisting Patient Financial Services staff with the investigation of reimbursement problems.
  • Communicating with patients and/or family members concerning insurance benefits, authorizations, self-pay arrangements, and medical necessity denials.
  • Educating patients and family members regarding any costs of care that may occur during treatment.
  • Meeting with managed-care companies to establish positive working relationships.
• Promote department goals and the mission of Rogers Behavioral Health by:
  • Communicating goals to fellow staff members.
  • Demonstrating measurable goal achievement.
  • Maintaining department policies and procedures, including requirements from external agencies (e.g., Joint Commission, State of Wisconsin).
  • Maintaining and communicating function backlog at set times.
  • Educating new staff regarding regulations or requirements related to their areas or departments.

Requirements

• Bachelor’s Degree is required; Behavioral Science is preferred.
• Two (2) years of previous work experience in an office or hospital setting is preferred.
• Knowledge of managed care, Medicaid, and Medicare.
• Utilization review experience in a hospital, outpatient, or managed care setting is preferred.
• Knowledge of the DSM, ICD-10, medical, mental health, and chemical dependency diagnosis and treatment processes.
• Computer skills, including word processing, spreadsheets, and data processing.
• Knowledge of Joint Commission documentation and medical records standards, with the ability to maintain accurate records.

Schedule

Monday - Friday, 8:00 AM - 4:30 PM.

This is a remote position, but the candidate must be local to Wisconsin to attend trainings and meetings.

Benefits

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