Education: Bachelor’s or Master’s degree from an accredited college or university in social work, mental health, nursing, or related degree preferred.
Experience: A minimum of two (2) years experience in a healthcare setting or managed care company, with experience in patient assessment, treatment planning, utilization management, and/or case management.
Case Management/Utilization Management
- Review the treatment plan and advocate for additional services as indicated.
- Promote effective use of resources for patients.
- Ensure that patient rights are upheld.
- Maintain ongoing contact with the attending physician, program manager, nurse manager, and various members of the team.
- Collaborate with the treatment team regarding continued stay and discharge planning issues.
- Advocate that the patient is placed in the appropriate level of care and program.
- Interface with program staff to facilitate a smooth transition at the time of transfer or discharge.
- Maintain documentation related to case management activities.
- Assure tracking of insurance reviews, and that reviews are completed in a timely manner.
- Maintain statistical reports and prepare documentation of significant findings.
- Communicate insurance requirements to all levels of staff.
- Provide timely updates regarding patient status on log sheets that are prepared for daily meetings concerning admissions, reviews, and discharges.
- Update the denial log statistics on an ongoing basis (at least weekly), and initiate appeals through telephone or written communication within 7 to 10 days of denial.
- Consult with the business office and/or admission staff as needed to clarify data and ensure the insurance precertification process is complete.
- Provide clinical information to managed care companies, insurance companies and other third party reviewers to establish the length of stay or number of certified days.
- Coordinate with the insurance company doctor in appeals process and denials process.
Treatment Planning
- Review assessment information.
- Attend and chair and coordinate treatment team continued stay reviews, as indicated.
- Communicate with attending physician and program managers, and other providers of service, to assure continuity of care, efficiency, and effective transitions between levels of care.
- Provide feedback to the attending physician and treatment team members concerning continuing certification of days/services.
- Communicate with external reviewers and referral sources. Conduct external reviews and maintain documentation of interactions.
- Ensure that third-party payers are notified of, or participate in, decisions about transitions between levels of care.
Discharge Planning
1. Coordinate discharge plans with the patient/family/significant/other, when indicated.
2. Ensure discharge appointments are made in keeping with insurance requirements.
Additional Responsibilities
1. Adhere to facility, department, corporate, personnel and standard policies and procedures.
2. Attend all mandatory facility inservices and staff development activities as scheduled.
3. Adhere to facility standards concerning conduct, dress, attendance and punctuality.
4. Support facility-wide quality/performance improvement goals and objectives.
5. Maintain confidentiality of facility employees and patient information.
KNOWLEDGE, SKILLS, AND ABILITIES
This section describes what knowledge, skills and abilities an employee in this position should possess. This list is not intended to be comprehensive.
1. Knowledge of case management techniques.
2. Knowledge of patient assessment and treatment planning techniques.
3. Knowledge of external review organizations (i.e. managed care, Medicare, Medicaid, etc.).
4. Knowledgeable about psychiatric patients’ rights issues.
5. Knowledge of crisis intervention techniques.
6. Knowledge of payer resources and financial planning
7. Excellent leadership and negotiation skills.
8. Excellent customer relations skills.
9. Excellent organizational and interpersonal communication skills.
10. Skill in interacting with multiple individuals with diversified roles and perspectives.
11. Skill in organizing and prioritizing workloads to meet deadlines.
12. Skill in telephone etiquette.
13. Effective oral and written communication skills.
14. Ability to communicate effectively both verbally and in writing.
15. Ability to handle conflicting situations.
16. Ability to focus on details in a busy environment.
17. Ability to work at a rapid pace in a fast-paced environment.
18. Ability to communicate effectively with patients and co-workers.
19. Ability to adhere to safety policies and procedures.
20. Ability to use good judgement and to maintain confidentiality of information.
21. Ability to work as a team player.
22. Ability to demonstrate tact, resourcefulness, patience and dedication.
23. Ability to accept direction and adhere to policies and procedures.
24. Ability to recognize the importance of adapting to the various patient age groups.
25. Ability to meet deadlines.
26. Ability to react calmly and effectively in emergency situations.
Ridgeview lnstitute - Monroe offers competitive rates and benefits; time off, medical, dental, vision, short term disability, long term disability, life insurance, and matching 401k.
