Description
We're a Little Different
Our mission is clear. We bring to life a healing ministry through our compassionate care and exceptional service.
At Mercy, we believe in careers that match the unique gifts of unique individuals – careers that not only make the most of your skills and talents, but also your heart. Join us and discover why Modern Healthcare Magazine named us in its “Top 100 Places to Work.”
Overview:
The Utilization Management Case Manager works as part of a team to provide referral, authorization, medical review, and/or case management services to providers and Health Plan members contracted with Mercy Managed Behavioral Health. Specific duties vary and are as assigned depending on the Health Plan's need. This position works alongside our BH Call Center and may be required to assist with incoming crisis calls or urgent requests from providers & members. This remote position requires active engagement and communication during the entire work shift, with the exception of coordinated breaks.
Call Center Support:
All team members must:
Utilize knowledge of BH system of care and clinical practice guidelines to provide telephonic assessment, triage, and referral of members to BH care.
Utilize strong customer support skills to provide compassionate care to members, care givers, and providers when needed.
Utilize clinical skills to handle emergency & crisis calls including safety planning and ensure appropriate follow up when needed.
Utilization Management:
When assigned UM tasks, the UM/CM must:
Perform pre-authorization, concurrent, and discharge review for members in any level of care (BH). This includes ongoing discharge planning and coordination with the facility UM to ensure the necessary information is obtained and timely.
Appropriately utilize medical necessity standards to ensure fair and consistent processing of authorization requests.
Coordinate with MMBH Medical Directors for timely staffing and determination when appropriate.
Provide timely notification of determination outcomes to providers and members.
Utilize understanding of the approval, denial, and appeal processes to provide appropriate guidance to providers or members when needed.
Complete timely referral to CM or EAP at discharge as needed.
Ensure timely documentation of all UM activities in the member's Electronic Health Record.
Case Management:
When assigned CM tasks, the UM/CM must:
Maintain a caseload of Health Plan members referred to or open in the Case Management Program. This includes following CM workflows and protocols to ensure timely outreach and follow up.
Provide compassionate care to members experiencing severe illnesses and high utilization.
Complete comprehensive assessment and treatment planning for our members with a BH diagnosis within the timeframe required by MMBH policy.
Utilize knowledge of community resources and supports, as well as BH services covered by their Health Plan, to reduce/remove barriers to accessing BH treatment.
Utilize short term clinical interventions to help members achieve their BH treatment goals. These could include motivational interviewing techniques, supportive listening and reframing, or coaching around coping strategies.
Provide ongoing support to the member to ensure follow through on self-care tasks and treatment recommendations. These could include routine review of medications to ensure the member is following doctor's orders or assistance contacting providers when the member is experiencing an issue with their medications or worsening symptoms.
Ongoing collaboration with the Health Plan's medical Case Management team to ensure comprehensive care.
Ensure timely documentation of all CM activities in the member's Electronic Health Record.
Quality Improvement:
Is aware of the QI Program components for MMBH and actively participates in QI activities as assigned.
Documents complaints, quality issues, etc. for QI Manager on QI form. Identifies Adverse events or other critical incidents and alerts their leader.
Manages all assigned work according to CMS and NCQA requirements.
Qualifications:
- Education: Registered Nurse or Masters in Social Work (MSW), Counseling (LCSW or LPC) or Psychology.
- Licensure: Current Registered Nurse, LCSW, LPC, or Psychologist licensed in state where applicant resides (this includes RN compact agreements); additional state licensure may be required depending on workload assignment
- Experience: At least two years post license direct clinical experience in a dedicated behavioral health setting is required. Applicants must demonstrate BH knowledge and treatment experience beyond medical management of someone with a BH diagnosis. This should include BH crisis resolution, use of BH screening tools, safety planning, and familiarity with BH interventions based on AMA & APA Standards of Care for BH diagnoses. Applicants must have broad knowledge of and experience with comprehensive BH assessment, care planning, and the BH system of care.
- Other: Broad Knowledge of mental illness/substance use diagnosis and treatment protocols required.Strong ethical awareness and decision-making skills required. Excellent communication and customer service skills required. Strong computer/technology skills required. Compassionate & warm approach to patient centered care required
- Preferred Experience: Prior Utilization Management or Case Management is strongly preferred. Prior experience working in a call center setting is preferred. Prior experience working with multiple different EHR's in a remote setting is preferred.
We Offer Great Benefits:
Day-one comprehensive health, vision and dental coverage, PTO, tuition reimbursement and employer-matched retirement funds are just a few of the great benefits offered to eligible co-workers, including those working 32 hours or more per pay period!
We're bringing to life a healing ministry through compassionate care.
At Mercy, our supportive community will be behind you every step of your day, especially the tough ones. You will have opportunities to pioneer new models of care and transform the health care experience through advanced technology and innovative procedures. We're expanding to help our communities grow. Join us and be a part of it all.
What Makes You a Good Match for Mercy?
Compassion and professionalism go hand-in-hand with us. Having a positive outlook and a strong sense of advocacy is in perfect step with our mission and vision. We're also collaborative and unafraid to do a little extra to deliver excellent care – that's just part of our commitment. If that sounds like a good fit for you, we encourage you to apply.
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