Reference #: 1006480SHIFT:Day (United States of America)

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　　Children's Hospital of Philadelphia (CHOP) offers countless ways to change lives. Our diverse community of more than 20,000 Breakthrough Makers will inspire you to pursue passions, develop expertise, and drive innovation.

　　At CHOP, your experience is valued; your voice is heard; and your contributions make a difference for patients and families. Join us as we build on our promise to advance pediatric care-and your career.

　　CHOP's Commitment to Diversity, Equity, and Inclusion

　　CHOP is committed to building an inclusive culture where employees feel a sense of belonging, connection, and community within their workplace. We are a team dedicated to fostering an environment that allows for all to be their authentic selves. We are focused on attracting, cultivating, and retaining diverse talent who can help us deliver on our mission to be a world leader in the advancement of healthcare for children.

　　We strongly encourage all candidates of diverse backgrounds and lived experiences to apply.

　　A Brief OverviewUnder the general supervision of the Inpatient Clinical Director, the Psychiatric Case Manager provides clinically based support to the multidisciplinary treatment team through reports of patient behavioral data as it relates to continued medical necessity for acute inpatient psychiatric care or crisis stabilization care. The Psychiatric Case Manager conducts concurrent reviews with payors as required to ensure continuous funding support for patients. The Psychiatric Case Manager maintains knowledge of the criteria of medical necessity for each level of care as well as individual payor requirements. Responsible for the overall onsite utilization review.

　　What you will doContinued stay authorization for psychiatric inpatient and crisis stabilization bedsProvides clinical information to outside review agencies to justify extensions using continued stay criteria: Collects, analyzes, and interprets data, determining importance of information collected, forming inferences and/or forecasts on how to utilize dataAssists clinical staff by collecting data as requested to assist in monitoring quality carePrepares monthly statistical reports on utilization review activities and additional narrative or statistical reports as requestedProvides ongoing education of clinical staff regarding insurance requirements and medical record documentationAttends treatment team meetings and rounds to coordinate with patient's care team as neededAttends individual patient huddles as indicatedConducts case review, including documentation preparation and coordination, to determine justification for appeals in instances where payment has been denied or will potentially be deniedManages calls to/from insurance providersUsing approved screening criteria, reviews and assesses appropriateness, in terms of medical necessity, of admissions and continued stay; will need to collate information from assessments done by provider/ clinical team membersActs as liaison between managed care company and clinicianReviews and assesses adequacy and appropriateness of clinical information being sent to insurance companiesPaired with a utilization review and financial case representatives to monitor and proactively communicate financial and insurance information to patients' treatment team to apprise them of third-party requirements that impact treatment plan and update them of current status of patients' use of benefits in order to maximize prompt collection for services and prevent bad debtWorks collaboratively with utilization review and finance office staff to ensure that patient services are covered by third party payer and that both the patient and treatment team are aware of any exceptions to coverageEducation QualificationsBachelor's Degree Social Work, Psychology or similar field of study RequiredMaster's Degree Social Work, Psych logy or similar field of study PreferredExperience QualificationsAt least five (5) years (with a Bachelor's Degree) experience in utilization review in healthcare is Required and experience in psychiatric utilization review preferred orAt least two (2) years (with a Master's Degree) experience in utilization review in healthcare Required and experience psychiatric utilization review preferred orSkills and AbilitiesAdhere to departmental policies, procedures, and objectives (Required proficiency)Ability to work collaboratively in a multi-disciplinary, heath care setting (Required proficiency)Ability to develop and maintain professional relationships with external stakeholders, inclusive of payor representatives (Required proficiency)Engages in self-performance appraisal, identifying areas of strength as well as areas for professional development (Required proficiency)Strong organizational skills with the ability to prioritize and work with multiple programs (Required proficiency)Ability to communicate effectively, verbally and in writing (Required proficiency)Ability to work in a fast paced environment (Required proficiency)Knowledge of hospital and community resources (Required proficiency)Performs other related duties as assigned (Required proficiency)

　　To carry out its mission, CHOP is committed to supporting the health of our patients, families, workforce, and global community. As a condition of employment, CHOP employees who work in patient care buildings or who have patient facing responsibilities must be fully vaccinated against COVID-19 and receive an annual influenza vaccine.

　　Employees may request exemptions for valid religious and medical reasons. Start dates may be delayed until candidates are immunized or exemption requests are reviewed.

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　　Children's Hospital of Philadelphia is an equal opportunity employer. We do not discriminate on the basis of race, color, gender, gender identity, sexual orientation, age, religion, national or ethnic origin, disability or protected veteran status.