Provides a professional clinical component to the Care Coordination process for patients admitted to the Behavioral Health unit which includes utilization review, case management, referral and discharge planning assistance to facilitate and implement a quality cost effective plan that meets or exceeds the needs of the patient and his/her family. The scope of the plan will include patient advocacy, case facilitation, crisis intervention, discharge planning, patient, staff and physician education, quality and process improvement as well as utilization management. Performs duties and responsibilities in a manner consistent with mission, values and Mercy service standards.
Job Description Responsibilities:
Coordination of Services:
1.Serves as advocate for patient/family and assists MH Case Managers/Therapists and other members of the Interdisciplinary team with utilization management, discharge planning needs, coordinating referrals and scheduling appointments for follow up services. 2. Works with the patient/family member, MH Case Managers/Therapists, Physicians, and entire Interdisciplinary team members to plan for the patients safe discharge and aftercare needs. 3. Ensures second opinion consultation is obtained as necessary. 4. Participates in QI activities that identify ways to improve patient care.
1. Possesses ability to perform pre-authorization, concurrent review, and discharge planning for patients admitted to behavioral health services. 2. Ensures that patients are in the appropriate level of care according to the clinical situation and prescribed plan of care. 3. Reviews the medical record for appropriateness and ensure medical necessity and continued stay criteria are met. 4. Understands and has knowledge of denial and appeal processes, peer review, timelines, and managed care processes. 5. Recognizes importance of case management for all patients especially those with severe illness and high utilization 6. Initiates and facilitates transfers as indicated. 7. Documents in appropriate authorization system information necessary for clinical authorization of services. 8. Prepares and refers cases to Physician Advisor/Medical Director for review appropriately.
1.Understands and utilizes professional skills in all communication 2. Possesses skills to handle emergency and crisis calls. 3. Communicates well with members/providers/ and other callers via telephone handling calls with knowledge, efficiency, and compassion. 4. Actively participates in the education of physicians and other members of the treatment team on appropriate utilization of services and level of care indicated by the clinical situation to achieve optimal reimbursement.
1. Maintain thorough documentation and documents in appropriate authorization system information necessary for clinical authorization of servcies.
1. Is aware of the QI Program components and actively participates in QI activities as assigned. 2. Documents complaints, quality issues, etc. as appropriate. 3. Identifies Adverse events or other critical incidents and alerts Manager.
1.Follows confidentiality policy with regard to patient information spoken, written or exchanged with others. 2. Complies with Infection Control guidelines 3. Complies with patient rights and regulations. 4. Adheres to hospital wide and department safety regulations.
Qualifications: Education: Registered Nurse, Masters in Social Work or Masters in Counseling required
Licensure: Registered Nurse (RN), Licensed Clinical Social Worker (LCSW) or Licensed Professional Counselor (LPC) in the state of Missouri required.
Experience: Minimum of 3 years direct clinical experience in psychiatric setting and at least two years of utilization management experience.
Other: Broad Knowledge of mental illness/chemical dependency diagnosis and treatment protocols required.
Preferred Certifications: Prefer Certification in Case Management
Preferred Other: Co-worker must be able to communicate orally, in writing and demonstrate proficient computer skills. Co-worker must be able to listen and to understand and explain complex situations. Knowledge of QI processes desirable.