Utilization Review Case Manager - Partial Hospitalization Program

About the role

• Luminis Health
• Title: Utilization Review/Case Manager-Partial Hospitalization Program
• Department: Lanham Partial Hospitalization
• Reports To: Director- Clinical Director Behavioral Health Lanham
• Cost Center/Job Code: 41000-42002-001148
• FLSA Status: Exempt

Position Objective

Performs and monitors integrated, concurrent utilization review and case referrals on patients, consistent with the approved Utilization Review Plans. Works with medical and professional staff to obtain appropriate clinical documentation for review and optimal patient placement. Maintains contact with Managed Care and other third party payors to assure appropriate case management.

Essential Job Duties

• Performs duties according to established standards for age groups adolescence through geriatric.
• Assesses data reflective of the patients status and interprets the appropriate information needed to identify each patients requirements relative to his or her age-specific needs. Maintains monthly statistical data and reports data to Clinical Director.
• Identifies status of physical, social and psychological needs of the patient, family and significant others.
• Evaluates data obtained in the bio-psychosocial and nursing history and assesses patients and their families to determine by interview, appropriateness for admission or referral.
• Determines the medical necessity and appropriateness of admission, using established criteria and standards.
• Verifies that pre-admission assessment is performed, and pre-authorizes patients as applicable.
• Monitors medical records for medical necessity and appropriateness of continued stay in accordance with established and approved norms.
• Verifies prior authorization data and performs concurrent reviews with external review agents on a daily basis in order to provide medical necessity and intensity of service information for continued stay approvals.
• Consolidates, tracks and reports performance on completed utilization review forms for all clinical areas and relays information to the multi-disciplinary treatment team.
• Resolves matters on outliers and initiates/follows up on appeals for determination at variance with program norm.

Educational/Experience Requirements

• BA/BS Degree, required
• Two years of experience performing utilization review or utilization management, preferred.

Working Conditions, Equipment, Physical Demands

There is a reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.

Physical Demands

The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.

Luminis Health Benefits Overview

• Medical, Dental, and Vision Insurance
• Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year)
• Paid Time Off
• Tuition Assistance Benefits
• Employee Referral Bonus Program
• Paid Holidays, Disability, and Life/AD&D for full-time employees
• Wellness Programs
• Employee Assistance Programs and more

• *Benefit offerings based on employment status
• Opt-in for text notifications!
• Luminis Health's two-way SMS texting platform lets you receive notifications and messages from our Talent Acquisition team directly on your phone.
• To enable this feature, select "yes" when asked to "opt-in to receive text messages" and to "Receive updates from a recruiter about this job via SMS" when completing your application. Once you are opted in, you can easily opt-out at any time.

• Standard text messaging rates may apply based on the candidate's mobile carrier plan.
• Luminis Health is not responsible for any charges incurred by the recipient.
• Candidates are encouraged to review their mobile carrier's plan for applicable text messaging rates and usage charges.