Job Description

The UTILIZATION REVIEW CASE MANAGER requires effective communication and coordination with the Director of Utilization Review, Operations, Billing, Contracting, Admissions and Clinical Outreach teams to maximize our ability to provide an appropriate and fully funded length of stay to each client. The Utilization Review Case Manager is responsible for overseeing all processes related to insurance authorization of Discovery Behavioral Health clients.

RESPONSIBILITIES

• Complete initial and concurrent reviews for a select number of MH RTC facilities
• Daily tracking and reporting of authorization status for all clients to assure that there are no unauthorized days as it pertains to insurance.
• Train and mentor all Discovery Behavioral Health clinicians and interns on a regular basis to assure consistently high levels of ability in presenting relevant criteria to insurance companies during the standard UR process.
• Oversee all higher- level appeals in conjunction with Clinical Appeals Specialist.
• Regularly audit clinical records to assure high quality documentation that supports good insurance authorization outcomes.
• Understanding DSM V diagnosis; ICD 10 codes and ASAM criteria and dimensions for all levels of care
• Communicate closely with Discovery Behavioral Health psychiatrists to support peer- to- peer reviews and to maintain awareness of strength of criteria that might support higher level appeals.
• Maintain close communication with the business office to minimize any unfunded treatment days and to assist with obtaining parent contracts.

This is ENTER DOL AND SHIFT SCHEDULE at one of our residential programs.  For a virtual tour of the facility, please visit our website at discoverymood.com.

Qualifications

• Extensive knowledge of the treatment of eating disorders, mental health disorders and substance abuse in children, adolescents and adults.
• An in-depth understanding of levels of care and relevant criteria.
• Current or past experience in providing utilization review, insurance authorization and an ability to advocate strongly for clients to receive appropriate levels of care.
• Strong writing skills and experience in preparing formal written appeals.
• Familiarity with the managed care system, benefit eligibility and appeals processes.
• A working understanding of medical complications associated with eating disorders, mental illness and substance abuse and the ability to articulate medical necessity at all levels of care.
• Record keeping must be accurate and thorough.
• An advanced degree and/or certification in mental health or nursing related field.

Additional Information

We are proud to be an EEO employer M/F/D/V. We maintain a drug-free workplace and perform pre-employment substance abuse testing. All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, or national origin.

For more information about our company benefits, please visit us at discoverybehavioralhealth.com/careers/