Lead Utilization Review, Case Manager

Havenwyck Hospital is a 243-bed Joint Commission accredited and licensed psychiatric hospital in Auburn Hills, Michigan. We specialize in providing comprehensive, compassionate behavioral health services to children, adolescents, and adults.

About the role

Havenwyck Hospital is seeking a dynamic and talented Quality Improvement Specialist to join our team of compassionate, dedicated professionals. The Lead Utilization Management (UM) Case Manager has responsibility for daily case assignments to the UM staff and the daily monitoring, tracking, and reporting of Medicare Certificates. The Lead UM Case Manager demonstrates understanding of the UM Review Process and acts as a resource for UM staff. Under the direction of the Director of UM, the Lead UM Case Manager develops procedures for UM departmental activities and processes and organizes and conducts the managed care process.

Responsibilities

• Conduct timely admission and continued stay record reviews with external payers, utilizing approved criteria to make determinations of medical necessity and level of care planning.
• Verify active treatment by completing internal audit reviews within approved time frames.
• Assist the treatment team when indicated in the discharge planning process.
• Act as liaison with MD/Clinical Treatment Team and external agencies.
• Report authorizations, denials, and documentation concerns, and collaborate effectively across departments to minimize denials/facilitate optimal use of hospital resources.
• On a daily basis, monitor admissions and continued stay reviews for RTC.
• Conduct medical necessity audits and chart reviews as needed.
• Provide coverage for the department in the absence of the UM Manager.
• Manage the assignment of cases to the UM staff and ensure equitable distribution of caseload.
• Monitor, track, and report Medicare Certificates and ensure their accurate completion by contacting the appropriate staff or physician.
• Demonstrate a higher understanding of the UM Review Process and act as a resource for UM staff.
• Develop and document procedures for UM departmental activities and processes under the direction of the UM Manager or Director.
• Report to external insurance and review entities an accurate presentation of the medical management of a patient’s illness, length of stay, and care alternatives within the confines of the client’s benefits and financial resources.
• Communicate with the Treatment Team (physicians, nursing staff, social workers, etc.) to advocate for the patient’s clinical treatment within the client’s benefits and financial resources.
• Assist the team in ensuring the completeness and accuracy of the medical record using clinical skills.
• Conduct phone, online, and fax reviews with managed care providers and relay clinical data in a professional, assertive, clear, and organized manner.
• Maintain a positive rapport with managed care providers; act as a representative of Havenwyck Hospital.
• Communicate results of reviews with physicians and team via direct contact, phone calls, and chart stickers.
• Communicate specific criteria and special requirements of managed care regarding discharge planning, family sessions, and treatment plans.
• Refer cases to the Physician Advisor/designee.
• Inform physicians of the need to contact managed care reviewers and follow up to ensure the call is made and ascertain the number of days obtained.
• Keep accurate records of days assigned to patients and when the next review is necessary.
• Maintain accurate accounting of authorized days from admission to discharge.
• Monitor and track the certification and re-certification process for Medicare patients to ensure all state and federal reporting guidelines are met.
• Maintain a flow of information by documenting in the internal electronic record (MIDAS) any information necessary for treatment team members to follow up on a case.
• Ensure accurate documentation of authorization status and provide appropriate information to the hospital fiscal department to assist in the timely filing of claims.
• Review cases on a daily basis, checking for discharges and day hospital admissions and relaying pertinent information.
• Act as a facilitator for the provider, payor, and patient in utilizing benefits in the most efficient and effectual manner.
• Possess a working knowledge of insurance verification and benefits.
• Demonstrate clinical skills including specific knowledge of diagnosis and dynamics involved in the treatment of psychiatric illnesses for patients of all ages.
• Attend hospital mandatory training/in-services as required in a timely manner.

Requirements

• Master’s degree in social work, psychology, or counseling; or a Bachelor’s degree in nursing required.
• Unrestricted and fully licensed (RN, MSW, LLMSW, LMFT, LP, LPC, etc.) required.
• A minimum of 2 years of post-graduate related experience in psychiatric or substance abuse treatment required.
• Able to establish professional relationships with all healthcare providers, work independently and collaboratively, have strong communication and organizational skills, attention to detail, and able to follow and manage multiple patient cases concurrently.
• Experience in settings that include inpatient or partial hospitalization preferred.
• Experience with managed health care processes, medical terminology, case management, discharge planning, and/or utilization review preferred.
• Strong organizational, writing, and speaking skills, as well as effective communication and interpersonal skills.
• Ability to work with a broad array of community-based service providers and an understanding of all applicable regulatory guidelines.
• Hospital utilization review/utilization management experience preferred.

Benefits

• Student Loan Repayment
• Challenging and rewarding work environment
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision, and Prescription Drug Plan
• 401(K) with company match and discounted stock plan
• Career development opportunities within UHS and its 300+ subsidiaries
• Free Basic Life Insurance
• Tuition Reimbursement
• SoFi Student Loan Refinancing Program