Senior Utilization Review Case Manager

Company Description

At Discovery Behavioral Health, we know the best way to predict the future of healthcare is to create it. As a member of our growing team, you will have a voice in the creation of life-changing programs and treatment centers nationwide. Working collaboratively with the best and the brightest in our industry, you will be part of an innovative team of professionals committed to generating positive and remarkable outcomes for the clients we serve. If you are looking for an organization that thrives on growth, celebrates diversity of thought, and rewards passionate execution, you’ve come to the right place. Because we put clients first, it is our honor to support and reward those who serve them.

Compensation Range: $75-82k per year.

Compensation will be dependent upon geographic region, education, and experience

Job Description

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.

Core Competencies:

• Deep understanding of the therapeutic process, confidentiality laws, and professional ethics.
• Ability to collaborate and communicate effectively with individuals from diverse educational and cultural backgrounds.
• Strong interpersonal skills with the ability to work across internal departments.
• Demonstrates professionalism, initiative, resourcefulness, and a non-judgmental attitude.
• Strong knowledge of personal and clinical boundaries.
• Ability to handle difficult, uncertain, and stressful situations with a positive and solution-focused approach.
• Exceptional verbal and written communication skills.
• Ability to work effectively within a team structure.
• Expertise in Medical Necessity Criteria for eating disorder treatment.
• Proficiency in electronic medical records (EMRs), particularly KIPU.

Qualifications

• Due to the nature of our business, we need a compassionate understanding person with:
• Master’s Degree preferred but not required
• Licensed LMFT, LCSW, LVN, or RN preferred but not required
• Strong knowledge of insurance and joint commission guidelines

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/

Discovery Behavioral Health seeks to build a diverse staff that is reflective of the patients we serve and the communities where we work. DBH encourages multiple perspectives, experiences, and strives to hire and retain a diverse workforce.

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