Case Management Lead

About the role

The CM Liaison Lead serves as a liaison between the SHC-VC Utilization Management/Case Management (UM/CM) team and health plans. This role acts as a resource to the UM/CM team members, processes authorizations within assigned scope, and oversees the CM Liaison Team in daily operations at Stanford Health Care Tri-Valley.

Responsibilities

• Utilize knowledge and experience to analyze contractual or administrative issues related to requests.
• Identify additional information needed and research benefits and criteria.
• Accurately determine when and how to refer cases to appropriate clinical personnel or take other required actions.
• Coordinate with insurance coordinators and medical review staff.
• Forward requests requiring additional clinical review for medical necessity to the pre-authorization nurse.
• Work independently and collaboratively with the clinical UM team to complete UM/CM work queues for ADT, rooming, medical necessity, and quality assurance.
• Assist the clinical UM team in validating physician orders and ensuring correct admission coding.
• Manage denial appeals, including preparation, submission within deadlines, and follow-up on outcomes.
• Develop and maintain systems to oversee all prior authorizations, ensuring timely and accurate completion of clinical information.
• Maintain contact with the CM/UM department to ensure proper handling of clinical interventions.
• Oversee the CM Liaison Team in daily operations.
• Assist with API and staffing schedules.
• Order medical, non-medical supplies, and transportation vouchers for the department.
• Contribute to department efficiency by being flexible and cross-trained on other functions.
• Work on special projects and assume other duties as assigned by the UM Director and CM Team leaders.
• Perform all duties in accordance with the C-I-CARE Standards of the Hospital.

Qualifications

Education

• High School Diploma or GED Required
• Associate's Degree Preferred
• Bachelor's Degree in Health or Business Administration Preferred

Experience

• 2 to 3 years of experience and training in Hospital Utilization Management, healthcare, and/or managed care Required

Knowledge, Skills, and Abilities

• Ability to make sound judgments
• Excellent communication and interpersonal skills
• Ability to work independently and function effectively as part of an interdisciplinary team
• Basic computer skills
• Strong advocacy and problem-solving skills
• Strong attention to detail
• Knowledge of acute care in relation to safety, security, and Joint Commission standards

Licenses and Certifications

• Current American Heart Association Certification for Basic Life Support for Healthcare Providers Required

Pay

Generally starting at $31.94 - $41.20 per hour. The salary of the finalist selected for this role will be set based on factors including internal equity, experience, education, specialty, and training.