Mercy Health

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Utilization/Case Manager

Utilization/Case Manager

Requisition ID 
2017-751014
Category 
Other Allied Health
Position Type 
Full Time
Shift(s) 
Days, Holidays
Department 
Administration-Beh Health
Location 
US-MO-Saint Louis

More information about this job

Overview

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We’re a Little Different

 

Our mission is clear. We bring to life a healing ministry through our compassionate care and exceptional service.  

 

We don’t believe in jobs 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.

 

At Mercy, you’ll feel our supportive community every step of your day, especially the tough ones. We’re a team and love working that way. That team is expanding, and we currently have exceptional opportunities to help our communities grow.

 

Overview:

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:

  • 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.
  • 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.
  • Ensures second opinion consultation is obtained as necessary. 
  • Participates in QI activities that identify ways to improve patient care. 

 

Utilization Management:

  • Possesses ability to perform pre-authorization, concurrent review, and discharge planning for patients admitted to behavioral health services.
  • Ensures that patients are in the appropriate level of care according to the clinical situation and prescribed plan of care. 
  • Reviews the medical record for appropriateness and ensure medical necessity and continued stay criteria are met. 
  • Understands and has knowledge of denial and appeal processes, peer review, timelines, and managed care processes.
  • Recognizes importance of case management for all patients especially those with severe illness and high utilization  
  • Initiates and facilitates transfers as indicated.
  • Documents in appropriate authorization system information necessary for clinical authorization of services. 
  • Prepares and refers cases to Physician Advisor/Medical Director for review appropriately.

Communication Management:

  • Understands and utilizes professional skills in all communication
  • Possesses skills to handle emergency and crisis calls.
  • Communicates well with members/providers/ and other callers via telephone handling calls with knowledge, efficiency, and compassion.
  • 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.

Record Keeping:

  • Maintain thorough documentation and documents in appropriate authorization system information necessary for clinical authorization of servcies.

Quality Improvement:

  • Is aware of the QI Program components and actively participates in QI activities as assigned.
  • Documents complaints, quality issues, etc. as appropriate. 
  • Identifies Adverse events or other critical incidents and alerts Manager.

Safety/Risk Management:

  • Follows confidentiality policy with regard to patient information spoken, written or exchanged with others.
  • Complies with Infection Control guidelines 
  • Complies with patient rights and regulations.
  • Adheres to hospital wide and department safety regulations.

Responsibilities and Qualifications

Qualifications:

 

We’re all unique pieces of a puzzle at Mercy, connected together to create a beautiful picture of health. And being the perfect fit for your role requires a specific set of qualifications that you’ll bring with you:

 

  • 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.
  • Certifications: 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.  

 

We’ll Support You at Work and Home

 

Our foundations are built on dignity and respect. Modern Healthcare Magazine named us as a “top 100 places to work.” We go out of our way to help people feel welcomed. We offer day-one comprehensive health, vision and dental coverage, PTO, and employer-matched retirement funds, even to part-time employees. We’re proud to provide tuition reimbursement to help you grow and learn new skills.

 

What Makes a Good Match for Mercy

 

Compassion and professionalism go hand-in-hand with us, along with exceptional quality care. Having a positive outlook and a strong sense of advocacy is in perfect step with our mission and vision. We’re also collaborative and are not afraid to do a little extra to deliver excellent care – that’s just part of our commitment. If that sounds like a fit for you as well, we encourage you to apply.

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