UR Case Management Specialist

Summary :

The UR Case Management Specialist provides leadership in the facilitation of the treatment process from admission to discharge. The UR Case Management Specialist monitors the treatment process, acting on behalf of the best interest of the patients, their families, and Rogers Behavioral Health to manage risk, ensure quality patient care and cost / quality outcomes. The UR Case Management Specialist collaborates with other departments to resolve identified care delivery issues at Rogers Behavioral Health.

Job Duties & Responsibilities :

Coordinate and Track Patient Care

• Act as the liaison between RBH and third-party payers in advocating for medical necessity authorization Provide utilization information to third- party payors and facilitate any physician-to-physician (peer to peer) reviews or expedited appeals.
• Act as a liaison between RBH, third-party payers, and non-RBH providers to ensure aftercare is complete with appointments scheduled.
• Attend and participate in interdisciplinary treatment team meetings.
• Review active medical records to ensure medical necessity documentation requirements are met and escalate documentation or quality care issues if needed.
• Communicate with utilization review (UR) leadership, admitting leadership, and clinical leadership regarding the quality of documentation within the medical record.
• Collaborate with admitting and clinical leadership in providing feedback, education and training to clinical staff regarding medical necessity documentation.
• Initiate the physician advisory review process as needed.
• Provide leadership in the facilitation between Rogers programs by acting as the primary liaison between admissions, clinical teams, payer strategies and patient financial services to ensure medical necessity authorization, single-case agreements or self-pay deposits are obtained.
• Inform UR leadership of any sensitive cases or potential cases involving p ayer strategies that may lead to contractual arrangements.
• Work with regulatory and / or quality department to identify, investigate, or resolve issues that place patients or Rogers Behavioral Health at risk.
• Maintain a list of specific resources to be used in accordance with best practice.
• Adhere to established Standard Work and ensure all documentation standards are met within required time frame.

Provide leadership in aftercare planning for all patients by coordinating the discharge planning process between all stakeholders including, but not limited to, patients / families, Rogers' clinicians, outpatient providers, insurance case managers, county services, legal, etc. to establish discharge plans that meet the clinical needs of the patient.

Support process improvement initiatives within the UR department.

Provide professional communication and customer service to all stakeholders.

Promote department goals as well as the mission of Rogers Behavioral Health.

Demonstrate understanding of Joint Commission and other regulatory agency compliance regulations.

Participate in committees, team meetings, and team projects, as directed.

Conduct self in a professional manner.

Perform other duties as assigned.

Additional Job Description :

Education / Training Requirements :

This position is hybrid, requiring some time in our Oconomowoc office.

With a career at Rogers, you can look forward to a Total Rewards package of benefits, including :

Through UnitedHealthcare, UMR and HealthSCOPE Benefits creates and publishes the Machine-Readable Files on behalf of Rogers Behavioral Health. To link to the Machine-Readable Files, please visit Transparency in Coverage (uhc.com)