Full-Time Senior Utilization Review Case Manager

The Senior Utilization Review (UR) Case Manager plays a key role in ensuring patients receive high-quality care by effectively coordinating with the Director of UR, VP of Clinical Operations, Division President, and treatment teams.

Acting as a liaison between clinical teams and other departments, this position is responsible for ensuring that documentation and utilization review processes meet Joint Commission and payer requirements. Additionally, the Senior UR Case Manager provides training and oversight to both centralized and decentralized facilities to ensure compliance and best practices.

Essential Job Functions:

• Conduct weekly training sessions on effective documentation and utilization review to ensure alignment with payer and Joint Commission guidelines, with quarterly reviews and updates as needed.
• Provide onboarding and oversight for new CFD hires on the utilization review process, occurring on the 2nd and 4th Monday of each month, for both centralized and decentralized facilities.
• Host weekly UR office hours to support clinical staff in understanding the UR process, presenting medical necessity, and conducting reviews at decentralized facilities.
• Offer collaborative UR calls and reverse shadowing for new hires at decentralized facilities.
• Ensure teams have a clear understanding of UR protocols and processes.
• Provide direct oversight of decentralized facility charts, offering feedback and guidance on UR entries and authorization documentation.
• Train and support decentralized facility staff in completing peer reviews when required by third-party payers, in consultation with the Director of UR, Program Director, DBH Appeals Team, and other relevant staff.
• Review documentation at all levels of care to ensure clinical appropriateness, quality and compliance.
• Maintain a professional demeanor and support the facility’s mission through effective communication and collaboration across departments.
• Contribute to facility-wide quality and performance improvement initiatives as directed by the Director of UR and VP of Clinical Operations.
• Involve facility leadership in key decisions and review them with the Director of UR before implementation.
• Conduct and manage initial insurance reviews and pre-authorizations for decentralized residential facilities, including assisting with initial authorizations for patients with new insurance policies.
• Provide coverage for initial, concurrent, and discharge reviews as needed.
• Assist the Director of UR in managing caseloads and reassigning reviews during staff absences.
• Support the CFD UR Team with urgent matters and provide oversight in the Director of UR’s absence.
• Represent UR Department professionally and positively across all interactions.
• Consistently Demonstrate excellent communication, prioritization, and multitasking skills.

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