Job Description

Location: St. Joseph Medical Center
Posted Date: 5/7/2020

JOB TITLE: Pool Utilization Review Case Manager

DEPARTMENT: BEHAVIORAL MEDICINE

SUMMARY

The Utilization Review Case Manager ensures patient treatment days through assisting with pre-certifications, concurrent reviews and discharges, as well as first level appeals with all managed care companies.

SERVICE

Consistently supports and communicates the Mission, Vision, and Values of St. Joseph Medical Center.
Upholds the Standards of Conduct and Corporate Compliance.
Consistently follows facility guidelines and procedures in performance.
Participates as an industrious member of the Utilization Review case management team.

Constant focus on customer service standards providing appropriate information and support to the leadership team and staff in maintaining and enhancing a culture of service excellence.

PEOPLE

Promotes of a culture of patient safety which results in the identification and reduction of unsafe practices.
Collaborates with colleagues both internal and external to ensure successful outcomes.

As an acting Patient Advocate ensures the resolution of problems and communication of procedures and services to maximize patient and family satisfaction.Must work harmoniously with physicians, clinical staff, nursing staff and administration.

DUTIES & RESPONSIBILITIES

QUALITY

Completes annual education requirements.
Follows the guidelines related to the Health Insurance Portability and Accountability Act (HIPPAA).
Monitors ICD-10 diagnoses. Ensures that documentation support managed care authorizations for continued hospitalization.
Ensures that the physician's certification and recertification letter for Medicare are signed within a timely manner according to CMS regulations. Performs all Medicare audits.Advocates for patient rights while supporting regulatory standards.
Promotes a culture of safety for patients and employees through proper identification, proper reporting and documentation.
Makes appropriate and timely decisions with regard to the patients benefits and utilization management needs.Other duties assigned.

GROWTH

Promotes stewardship of hospital resources while ensuring quality patient care.
Maintains competency of Utilization management and knowledge of current trends in Managed care, Medicaid and Medicare.
Contributes to improving Hospital Based Inpatient Psychiatric Services (HBIPPS).
Maintain a constant focus on customer service to maximize patient and family satisfaction.
Contributes to improving Hospital Based Inpatient Psychiatric Services (HBIPPS).
Maintain a constant focus on customer service to maximize patient and family satisfaction.

FINANCE

Promotes stewardship of hospital resources while ensuring quality patient care.

Obtains treatment authorizations with insurance providers by completing the Utilization Review process from precertification, concurrent review and discharge documentation.

Completes first level appeals with all managed care companies to assist with overturning denials for inpatient hospitalization.

Confirm and verify that all documentation supports authorizations for continued hospitalization.

MINIMUM KNOWLEDGE, SKILLS & ABILITIES

LICENSE/REGISTRATION/CERTIFICATION:

Licensure preferred but not required: A minimum of a Bachelor’s Degree with and advanced level of knowledge and skill base in the area of utilization review and case management.

Technical, clerical, critical thinking and excellent interpersonal skills.

Other certification requirements as defined by the certification policy. (BLS required).

Able to communicate effectively in English, both verbally and in writing.

PREFERRED:

LMSW, LPC Licensed by (DSHS-TX) or RN, Licensed by (TX. Board of Nursing).

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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