Utilization Manager

5 days ago

Chicago, Illinois, United States Carolina Therapeutic Services Health Full time
Job Title: Utilization Manager

Job Summary:

The Utilization Manager will play a critical role in ensuring the continuity of care and quality of service to consumers. This position will serve as a liaison between the Utilization Department and various stakeholders, including Lead Therapists, Therapists, Case Managers, and Service Coordinators.

Key Responsibilities:
  • Client Rights: Ensure that client rights are being adhered to for all consumers.
  • Regulatory Compliance: Responsible for attending to all rules and regulations of the agency, state, and federal statues, and attending rules of quality improvement, medical records, finance, etc. of the agency.
  • Authorization Management: Submit Initial and Concurrent Authorizations to MCOs for assigned contract areas by completing/updating authorization requests forms as needed.
  • Documentation and Tracking: Document work, update and maintain trackers (ICAN, Referral, Master tracker) supplied by supervisor and submit to necessary parties as required by supervisor.
  • Insurance Verification: Verify client insurance coverage for authorization submission.
  • Communication: Coordinate with MCO to resolve documents issues submitted for authorizations.
  • Referral and Intake Management: Gather and review accuracy and complete all referral forms, intake forms, ICAN/Screenings forms prior to submitting to MCO.
  • Program Management: Communicate with program managers when authorizations are completed, and clients are ready to be billed. Provide program managers electronic copy of ICANs.
  • Quality Assurance: Track and review ICANs/Screening scores for accuracy all new clients for completion of intake, ICANs/Screenings. Communicate to Therapist Lead and Intake Coordinator if not completed in timely manner.
  • Client Data Management: Add client demographics and client goals and update as needed to OnTarget system.
  • Authorization Management: Identify and add authorizations for ICANs/Locus, OPT, CM, CS, PSR (update as needed).
  • Beacons and Reporting: Complete initial and updated Beacons.
  • Critical Concerns: Report critical concerns and problems to supervisor in a timely manner and actively seek supervisor's input and assistance to resolving the concern.
  • Reporting and Communication: Reports to supervisor on a weekly basis.
Consumer Charts:
  • Medicaid Verification: Verify Medicaid approval on all potential consumers.
  • Support Documentation: Request support documentation from case workers, case manager, and therapist as needed.
  • Chart Preparation: Print all forms (the corrected version) and provide to audit authorization for client's chart.
  • Extension and Denial Management: Process generated extensions or denial letters.
  • Audit Participation: Participate in state and local audits.
Professional Responsibilities:
  • Confidentiality: Maintain strict confidentiality according to all Federal and State guidelines and requirements.
  • Code of Ethics: Uphold the Code of Ethics both professional and personally.
  • Communication: Maintain a cooperative relationship with all staff and others by demonstrating tact, courtesy, and a positive approach to communication.
  • Facility Support: Support facility programs and activities.
  • Personal Development: Responsible for personal development to ensure current knowledge in the profession.
  • Work Environment: Responsible for maintaining a safe, clean and drug free environment.
Communication:
  • Information Sharing: Communicate pertinent Consumer and Stakeholder information to other employees/team members to insure quality of care.
  • Teamwork: Work with a team approach with other employees to ensure efficacy of care for ALL Consumers.
  • Problem Solving: Follow chain of command when encountering problems or other areas of need and correct problems requested.
  • Assistance Seeking: Solicit and cooperate with assistance of all support staff.
  • Decision Making: Actively participate in an appropriate manner with the decision-making process as pro-active team member and cooperate with team's decision, whether programmatic or clinical.
  • Availability: Provide coverage on-site or as assigned by the needs of the agency.
  • Meetings and Training: Attend staff meetings, planned in-service training and any other regular or assigned meetings.
  • Equipment Maintenance: Responsible for any equipment assigned in order to perform duties.
  • Information Flow: Facilitate flow of information, particularly as it affects the delivery of services to consumers.
  • Additional Duties: Perform other required job duties that the supervisor and/or director require to maintain continuity of care for consumers and profitability for the agency.
Hours of Work:

There is no shift rotation as such, however due the specialized nature of position; it is expected, that the employee will work the hours needed for client services as determined by the supervisor, agency coordinator, treatment team, and Carolina Therapeutic Services Inc. It is likely that this will occur somewhat regularly. Assignments can occur on weekends and after hours. Due to this after hours work, weekend work can also be assigned as defined by the needs of the client population.

  • Self-Monitoring: Self-monitor the use of own time and the time of co-workers if it affects this position in the areas of service delivery, work hours, schedule, breaks, lunches, etc. Report any needs in this area to the supervisor and/or chain of command.
  • Shift Variance: Shift variance to meet the needs of the clients.
  • After Hours Calls: Respond to pages or after hour calls in accordance to procedures.
  • On-Call Support: Ability to provide twenty-four coverage and on-call support as scheduled/needed.
  • Meetings and Functions: Attend all meetings and functions as required.
Qualifications and Education Requirements:
  • Age and Literacy: Must be at least 18 years of age, be able to read, write and effect both written and verbal communication successfully.
  • Understanding and Following Directions: Understand and follow directions.
  • Criminal Background Check: Possess no substantiated findings of abuse or neglect listed on Health Care Registry, and no criminal convictions.
  • Education: Higher school diploma or its equivalent.
Work Requirements and Certification/Licenses Requirements:
  • Orientation: Orientation to CTS Inc.
  • Training: Receive training in population served, and client's rights/confidentiality.
  • Experience: Experience with HIPAA and System Of Care is required.
  • Training Participation: Participate in and successfully complete all required trainings.
  • Credentialing: The employee must become privileged/credentialed in delivery of services.
  • CPR/First Aid and Medication Administration: CPR/First Aid, Medication Administration and Preventive Disease will be required.
  • Core Skills and Training: Demonstrate core skills and training to deliver services.
  • Transportation: Must have adequate transportation to deliver services, maintain required level of vehicle insurance in order to deliver services necessary to participate in consumer activities, i.e. hiking, sporting, education, etc.
  • Criminal Records Check: Criminal records check, finger printing, and HCPR check is a prerequisite for employment consideration.
  • Driver's License: Maintain a Valid Driver's License or State Identification.

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