Utilization/Case Manager
Company: Mercy Health
Location: Chesterfield
Posted on: April 26, 2025
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Job Description:
We're a Little Different
Our mission is clear. We bring to life a healing ministry through
our compassionate care and exceptional service.
At Mercy, we believe in careers that match the unique gifts of
unique individuals - careers that not only make the most of your
skills and talents, but also your heart. Join us and discover why
Modern Healthcare Magazine named us in its "Top 100 Places to
Work."
Overview:
Provides referral, authorization, medical review, and case
management services for members covered through Mercy Managed
Behavioral Health. Assists with quality improvement program and the
integration of QI processes into Medical Management as
assigned.
Qualifications:
Assessment/Referral and Utilization Management:
1. Understands and utilizes professional skills in triaging phone
calls to refer to appropriate provider/level of care/ or
services.
2. Possesses skills to handle emergency and crisis calls.
3. Communicates well with members/providers/ and other callers via
telephone handling calls with knowledge, efficiency, and
compassion.
Utilization Management:
1. Possesses ability to perform pre-authorization, concurrent
review, and discharge planning for members in any level of
behavioral health care.
2. Understands and has knowledge of denial and appeal processes,
peer review, timelines, and managed care processes for UM
activities.
3. Understands and recognizes the role of EAP and recommends when
appropriate for clients with that employer benefit. Prepares and
refers cases to Medical Director for review appropriately.
Case Management:
1. Recognizes importance of Case Management (CM) for members with
severe illnesses and high utilization.
2. Depending on assignments either refers members to CM, or manages
patient care through CM processes.
3. Understands value and recognizes importance of treatment follow
up and compliance, as well as external resources and services.
Record Keeping:
1. Documents in appropriate electronic health record information
necessary for clinical authorization of services.
2. Utilizes QI form for documentation of QI or other Adverse
issues.
Quality Improvement:
1. Is aware of the QI Program components for MMBH and actively
participates in QI activities as assigned.
2. Documents complaints, quality issues, etc. for QI Manager on QI
form. Identifies Adverse events or other critical incidents and
alerts their leader.
We Offer Great Benefits:
Day-one comprehensive health, vision and dental coverage, PTO,
tuition reimbursement and employer-matched retirement funds are
just a few of the great benefits offered to eligible co-workers,
including those working 32 hours or more per pay period!
We're bringing to life a healing ministry through compassionate
care.
At Mercy, our supportive community will be behind you every step of
your day, especially the tough ones. You will have opportunities to
pioneer new models of care and transform the health care experience
through advanced technology and innovative procedures. We're
expanding to help our communities grow. Join us and be a part of it
all.
What Makes You a Good Match for Mercy?
Compassion and professionalism go hand-in-hand with us. Having a
positive outlook and a strong sense of advocacy is in perfect step
with our mission and vision. We're also collaborative and unafraid
to do a little extra to deliver excellent care - that's just part
of our commitment. If that sounds like a good fit for you, we
encourage you to apply.
EEO/AA/Minorities/Females/Disabled/Veterans
Keywords: Mercy Health, O'Fallon , Utilization/Case Manager, Executive , Chesterfield, Missouri
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