Case Manager (Psych - UR) - Full Time, Days (Culver City)

The Case Manager, UR is responsible for overseeing the daily operations of the assigned caseload. Ensures Medical Necessity for patient admission and concurrent stay at the short-term acute hospital level of care are met, utilizing the facility approved non-MD reviewer guidelines.

Communicates as appropriate to the payer. Refers all cases not meeting MN for second level review. Ensures a safe and timely discharge / transition to the next appropriate level of care.

Ensures timely escalation of unresolved care coordination issues to the appropriate level / entity. Enters delays in service and avoidable days regarding exceeded payer LOS variances.

Communicates denials and physician related utilization management practices to immediate supervisor same day as identified.

Keeps facility administration and CM Manager / Director of Utilization Management aware of any daily operational / physician related issues.

Works closely with the facility Physician Advisor and Corporate. Works collaboratively with health care team, patients and families, administration and members of the Medical Staff.

Responsible for active participation in daily weekday intra disciplinary patient rounding.

Completes TAR for assigned Medi-Cal patient population / obtains authorizations for managed care accounts and submits appeals for all denied cases.

Maintains confidentiality of all information according to Hospital Policy and Procedure and legal and regulatory requirements.

Reviews hospital admissions and continued stays in accordance with procedures, criteria, and standards approved by the medical staff.

Identifies opportunities for improvement in the current processes and procedures. Escalates unresolved issues to direct supervisor of UM Facility Administrator per escalation process.

Collaborates with Social Services, Clinical Team, patient and families to prepare patient’s discharge planning needs. Oversees appropriate DC documentation.

Works with Social Service to perform a variety of miscellaneous services, such as arranging for discharge or post-hospital plans, placement of patients in skilled nursing facilities or board an care homes.

Required Qualifications :

• Current Licensure as a Vocational Nurse or LPT in the State of California
• Two (2) years of experience in utilization review / management in a managed care or hospital setting.
• Knowledge of The Joint Commission and Title XXII regulations
• Knowledge of CMS, MCARE, MEDI-CAL and Managed Care Reimbursement.
• Knowledge in insurance authorization and verification
• Knowledge of Interqual and / or Milliman Care criteria
• Excellent written and verbal communication skills in English
• Computer / EMR Proficiency
• AHA Basic Life Support
• De-escalation certification upon hire; Upon recertification, SAMA Certification required
• Hospital Fire and Life Safety Card (Los Angeles City Employees only)

Preferred Qualifications :

• Three (3) years clinical experience in psychiatric hospital setting.
• Care Management Proficiency with Milliman Care Guidelines or Interqual

Pay Rate : Min - $34.15 Max - $45.88