Utilization Review/Case Manager

Position Summary

The Utilization Review/Case Manager is responsible for coordinating all aspects of utilization management, insurance authorization, concurrent reviews, discharge planning, and continuity of care for patients admitted to the psychiatric hospital. This position serves as a liaison between physicians, insurance companies, patients, families, and community providers to ensure appropriate levels of care, timely authorizations, and safe discharge planning.

Essential Job Responsibilities

Utilization Review

• Complete admission reviews and obtain insurance authorizations.
• Perform concurrent reviews with commercial insurance, Medicare Advantage, Medicaid Managed Care, and other third-party payers.
• Submit clinical documentation supporting medical necessity.
• Coordinate peer-to-peer reviews when required.
• Monitor authorization status and approved lengths of stay.
• Manage denial prevention and appeal processes.
• Maintain accurate utilization review documentation.
• Ensure compliance with payer guidelines and regulatory requirements.
• Track authorization dates and notify providers of pending reviews.

Case Management

• Complete psychosocial and discharge planning assessments.
• Coordinate interdisciplinary treatment planning.
• Develop individualized discharge plans beginning at admission.
• Arrange follow-up appointments with outpatient providers.
• Coordinate referrals to:
  • Intensive Outpatient Programs (IOP)
  • Partial Hospitalization Programs (PHP)
  • Community Mental Health Centers
  • Primary Care Providers
  • Nursing Facilities
  • Assisted Living Facilities
  • Home Health Agencies
  • Substance Use Treatment Programs
• Arrange transportation for discharge when needed.
• Collaborate with families and caregivers throughout hospitalization.
• Coordinate transfers to higher or lower levels of care as appropriate.

Care Coordination

• Participate in daily treatment team meetings.
• Collaborate with psychiatrists, nursing staff, therapists, social workers, and administration.
• Communicate with insurance case managers and payer representatives.
• Ensure continuity of care following discharge.
• Facilitate patient and family meetings as needed.

Documentation

• Maintain complete, accurate, and timely documentation within the electronic medical record.
• Document utilization reviews, discharge planning activities, and communications with payers.
• Maintain records supporting medical necessity and reimbursement.
• Ensure documentation meets CMS, Joint Commission, and Mississippi Department of Health requirements.

Regulatory Compliance

• Maintain compliance with:
  • CMS Conditions of Participation
  • Joint Commission standards
  • HIPAA
  • Mississippi Department of Health regulations
  • Hospital policies and procedures
• Participate in quality improvement and survey readiness activities.

Qualifications

Required

• Minimum of two years of experience in behavioral health, case management, utilization review, or discharge planning.
• Strong knowledge of behavioral health levels of care and medical necessity criteria.
• Excellent communication and organizational skills.
• Computer proficiency and experience with electronic medical records.

Preferred

• Behavioral Health or Psychiatric Hospital experience.
• Experience with Medicare, Medicaid, and commercial insurance authorizations.
• Knowledge of InterQual® or MCG® medical necessity criteria.
• Experience with utilization review and denial management.
• Discharge planning and community resource coordination.

Benefits

• Competitive salary
• Medical, dental, and vision insurance
• Paid Time Off (PTO)
• Paid holidays
• Retirement plan
• Continuing education opportunities
• Supportive team environment
• Professional growth and advancement opportunities