What are the responsibilities and job description for the Clinical Case Manager position at St. Charles Health System?
The Case Manager provides therapeutic services and discharge planning in support of Master’s-level therapists and psychiatrists in Psychiatric Emergency Services (PES) and Sage View. This position also performs utilization review, assists with pre-authorizations, and monitors accounts for accuracy of charges and determines appropriate payment. The Case Manager is responsible for: economic assessments that assist with determining disposition, providing skills groups, facilitating care coordination meetings with community stakeholders, and tracking/monitoring patient care metrics. This position coordinates with appropriate after-care providers and collaborates with community partners in setting up optimal discharge plans for patients. The Case Manager assists with the training of new intake staff on insurance and billing requirements but does not directly manage any other caregivers.
Essential Functions And Duties
Performs patient chart reviews for appropriateness and medical necessity of admissions, continued stays, and supportive services to promote quality care and cost effectiveness while maintaining ongoing insurance contact and providing clinical documentation and reviews to insurance companies as requested for purposes of ongoing authorization of hospital stays.
Serves as a resource and provides education to physicians and unit staff on inpatient psychiatric medical necessity criteria and appropriate level of care.
Identifies and reports quality of care issues through the EMS system or immediately if indicated, to Risk Management.
Participates in medical necessity denials and appeals processes. Ensures prompt and accurate follow up to ensure resolution and timely billing.
Participates in facilitating patient’s and family’s learning throughout the continuum of care. Reinforces patient’s continued health care through teaching and/or referral to community agency follow-up.
Performs patient assessment of social, economic, emotional, and family situations. Responsible for completion of Economic & Discharge Assessment.
Functions as a member of the Interdisciplinary Treatment Team to assure care is accomplished effectively and efficiently in a cost-effective manner. Both facilitates and participates in clinical care conferencing with community stakeholders.
Provides assessment of Social Determinants of Health and connects patient with resources as appropriate. Coordinates aftercare for patients including arranging therapeutic appointments, medication management, and follow up medical appointments within a timeframe that meets Oregon State healthcare metrics.
Awareness, ability, and willingness to work with out-of-area service providers to ensure optimum aftercare resources.
Respects the privacy and protects the confidentiality of patients and family members while maintaining the boundaries of the professional discipline.
Obtains and maintains an Oregon Health Plan-certified Community Partner designation for understanding health coverage options. Helps patients complete eligibility and enrollment forms when necessary.
Maintains knowledge of all state and federal regulations as they apply to the admission, care, and discharge of patients from an inpatient psychiatric facility including all pertinent civil commitment procedures/protocols.
Supports the vision, mission, and values of the organization in all respects.
Supports LEAN principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
Provides and maintains a safe environment for caregivers, patients, and guests.
Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient, and accurate.
Participates in creating a healing environment that supports all aspects of the care environment and the wholeness of each individual patient and caregiver.
Provides a therapeutic presence in service to others by purposefully responding to the needs of patients in a caring way, including introducing oneself and explaining role in patient’s care, asking the patient their preferred name, sitting with the patient to determine their care goals, active listening, and communicating effectively and appropriately through touch, eye contact, etc.
Conducts all activities and documents them with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.
May perform additional duties of similar complexity within the organization, as required or assigned.
Education
Required: Bachelor’s degree in a behavioral health-related field or equivalent.
Preferred: Graduate degree in Mental Health Counseling or Social Work.
Licensure/Certification/Registration
Required: Valid Oregon driver’s license and ability to meet SCHS driving requirements. Certified Qualified Mental Health Associate (QMHA) with the Mental Health & Addiction Certification Board of Oregon (MHACBO) or ability to become a QMHA within 30 days of hire. AHA Basic Life Support for Healthcare Provider certification.
Preferred: QMHA, CADC. Oregon Health Plan Assistor certification.
Experience
Required: Familiarity with psychiatric terminology and experience working with those struggling with severe and persistent mental illness.
Preferred: One (1) year experience providing case management in an inpatient or outpatient health services program. Familiarity with pre-authorizations, continued review, and billing/claims of mental health accounts.
Essential Functions And Duties
Performs patient chart reviews for appropriateness and medical necessity of admissions, continued stays, and supportive services to promote quality care and cost effectiveness while maintaining ongoing insurance contact and providing clinical documentation and reviews to insurance companies as requested for purposes of ongoing authorization of hospital stays.
Serves as a resource and provides education to physicians and unit staff on inpatient psychiatric medical necessity criteria and appropriate level of care.
Identifies and reports quality of care issues through the EMS system or immediately if indicated, to Risk Management.
Participates in medical necessity denials and appeals processes. Ensures prompt and accurate follow up to ensure resolution and timely billing.
Participates in facilitating patient’s and family’s learning throughout the continuum of care. Reinforces patient’s continued health care through teaching and/or referral to community agency follow-up.
Performs patient assessment of social, economic, emotional, and family situations. Responsible for completion of Economic & Discharge Assessment.
Functions as a member of the Interdisciplinary Treatment Team to assure care is accomplished effectively and efficiently in a cost-effective manner. Both facilitates and participates in clinical care conferencing with community stakeholders.
Provides assessment of Social Determinants of Health and connects patient with resources as appropriate. Coordinates aftercare for patients including arranging therapeutic appointments, medication management, and follow up medical appointments within a timeframe that meets Oregon State healthcare metrics.
Awareness, ability, and willingness to work with out-of-area service providers to ensure optimum aftercare resources.
Respects the privacy and protects the confidentiality of patients and family members while maintaining the boundaries of the professional discipline.
Obtains and maintains an Oregon Health Plan-certified Community Partner designation for understanding health coverage options. Helps patients complete eligibility and enrollment forms when necessary.
Maintains knowledge of all state and federal regulations as they apply to the admission, care, and discharge of patients from an inpatient psychiatric facility including all pertinent civil commitment procedures/protocols.
Supports the vision, mission, and values of the organization in all respects.
Supports LEAN principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
Provides and maintains a safe environment for caregivers, patients, and guests.
Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient, and accurate.
Participates in creating a healing environment that supports all aspects of the care environment and the wholeness of each individual patient and caregiver.
Provides a therapeutic presence in service to others by purposefully responding to the needs of patients in a caring way, including introducing oneself and explaining role in patient’s care, asking the patient their preferred name, sitting with the patient to determine their care goals, active listening, and communicating effectively and appropriately through touch, eye contact, etc.
Conducts all activities and documents them with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.
May perform additional duties of similar complexity within the organization, as required or assigned.
Education
Required: Bachelor’s degree in a behavioral health-related field or equivalent.
Preferred: Graduate degree in Mental Health Counseling or Social Work.
Licensure/Certification/Registration
Required: Valid Oregon driver’s license and ability to meet SCHS driving requirements. Certified Qualified Mental Health Associate (QMHA) with the Mental Health & Addiction Certification Board of Oregon (MHACBO) or ability to become a QMHA within 30 days of hire. AHA Basic Life Support for Healthcare Provider certification.
Preferred: QMHA, CADC. Oregon Health Plan Assistor certification.
Experience
Required: Familiarity with psychiatric terminology and experience working with those struggling with severe and persistent mental illness.
Preferred: One (1) year experience providing case management in an inpatient or outpatient health services program. Familiarity with pre-authorizations, continued review, and billing/claims of mental health accounts.