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RN Case Manager - Behavioral Health Utilization Review
Join a dedicated healthcare team in the Midwest region as a Registered Nurse Case Manager specializing in behavioral health utilization review. In this role, you will collaborate closely with healthcare providers and members to evaluate patient needs and benefit requirements, ensuring optimal resource use. You will manage patient cases within the behavioral health unit, reviewing medical necessity for admissions, continued stays, and services.
Essential Responsibilities:
- Assess patient situations and conduct reviews to ensure compliance with eligibility, benefits, policies, and contracts.
- Manage appeals and coordinate comprehensive reviews of medical records to verify accurate admission and diagnosis information.
- Promote improved quality of care and support reduced hospital stays when safe and appropriate.
- Advise pre-certification staff and maintain records and reports related to non-clinical activities.
- Coordinate with insurance companies to secure authorizations for behavioral health services, ensuring adherence to payer requirements and facility standards.
- Maintain thorough documentation of utilization review activities, including clinical justifications and authorization requests.
- Assist with triage screenings for incoming behavioral health patients to determine immediate care needs and facilitate timely care delivery.
- Provide psychosocial support to patients and families, addressing emotional, social, and financial barriers.
- Serve as a liaison between healthcare teams and patients/families to ensure smooth care transitions.
- Support discharge planning processes when needed, ensuring safe and appropriate discharge plans.
- Conduct safety assessments and make protective reports for adults and children as indicated.
- Participate in ongoing professional development and mandatory training, including de-escalation techniques.
- Adhere to privacy and security regulations regarding Protected Health Information (PHI).
- Maintain effective communication and professional relationships with patients, team members, physicians, and external agencies.
- Graduate of a nursing or Bachelor of Social Work (BSW) program.
- Experience in behavioral health settings, particularly crisis management and inpatient care.
- Current licensure as a Registered Nurse (RN) or BSW in the relevant state.
- Current Basic Life Support (BLS) certification from American Heart Association or American Red Cross within 30 days of hire.
- De-escalation training required within six months of start date.
- Experience in utilization review, insurance coordination, and interdisciplinary team collaboration.
- Advanced degrees such as BSN or MSW are a plus.
- Strong collaboration skills with interdisciplinary teams to ensure high-quality care.
- Familiarity with community resources, mental health services, and post-acute care.
- Basic computer proficiency and experience documenting in electronic health records.
- Ability to multitask, prioritize, and communicate effectively.
Physical Requirements: Medium work involving occasional exertion up to 50 lbs and frequent standing or walking (26-50% of the day).
This position offers a competitive salary and benefits package, providing a meaningful opportunity to impact behavioral health care in a supportive regional healthcare environment.
