Utilization Review Case Manager

Utilization Review Case Manager

Status: Full-Time, Non-Exempt, Hourly

Schedule: 8:00am-4:30pm PST

Join AMFM Healthcare!

The Utilization Review (UR) Case Manager serves as a key member of the interdisciplinary team and actively manages and directs insurance utilization throughout a client's treatment episode, from admission to discharge while working with several departments including Admissions, Billing, Compliance, and Clinical, and plays an active role in treatment team discussions. The UR Case Manager acts as a liaison between insurance and facility/clinical teams while coordinating with discharge planners on estimated step down or discharge dates and insurance recommendations. UR Case Managers are responsible for their own assigned caseload including initial, concurrent, and discharge reviews, peer reviews, and expedited appeals and will oversee the effective coordination of services and manage issues in the following areas: admission and discharge, team conferences and plan of care communication, patient and family education when necessary, and payor relations.

About Us

AMFM Healthcare is a leading provider of evidence-based mental health treatment with programs spanning California, Washington, Virginia, and Minnesota. We are committed to delivering compassionate, individualized care through a network of specialized programs that support people across all stages of life and levels of need.

Our mission is to provide high-quality mental health treatment in settings that foster healing, connection, and long-term wellness. Every program under the AMFM umbrella is grounded in clinical excellence, integrity, and a deep respect for the personal stories of those we serve.

Our Programs Include:

• A Mission for Michael: Our flagship program offers intensive, highly personalized residential mental health treatment in small, home-like environments. With a 6-8 client ratio per home, we provide 24/7 support from a multidisciplinary clinical team, incorporating traditional therapy, experiential modalities (art, music, equine), and a deep focus on each client's lived experience.
• Mission Connection: A flexible, hybrid program designed to meet clients where they areboth literally and clinically. This outpatient service combines in-person and telehealth care for adults with primary mental health diagnoses such as anxiety, depression, and mood disorders. Mission Connection ensures consistent, personalized support that fits into the client's real life.
• Mission Prep: A dedicated adolescent program that works with teens and their families to create sustainable change. Focused on treating primary mental health challenges, Mission Prep offers a blend of proven therapies and innovative interventions in a supportive, home-like setting. Family involvement is central to the treatment process, helping lay the foundation for long-term success and resilience.

From residential programs to hybrid and outpatient care, AMFM Healthcare is proud to offer a full continuum of mental health treatment options, delivered by passionate professionals who believe in treating the whole personnot just the diagnosis.

Qualifications:

1. Must be 18 years or older to apply for this position.
2. Ability to pass a standard background check.
3. Minimum Education Requirement: High School Diploma or equivalent.
4. At least 6 months experience working in the behavioral health or substance abuse field, with knowledge of general medical necessity and insurance criteria.
5. Physical Requirements: Ability to work on a computer/keyboard, type a minimum of 40 words per minute, use electronic systems, communicate with others through written and verbal formats, ability to sit for long periods of time, listening, reading comprehension, lifting up to 10 lbs.

To perform this job successfully, an individual must be able to perform each essential job function assigned satisfactorily. The requirements listed above are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Knowledge, Skills, and Abilities:

1. Excel at both written and verbal communications to convey essential information; must be able to utilize the proper linguistic syntax and spelling.
2. Ability to use computer software including Microsoft Office, Adobe Acrobat, and G Suite products.
3. Knowledge of clinical and medical terminology as it relates to the delivery of clinical care to the clients within our programs.
4. Ability to operate standard office machines and equipment, including telephones, computers, copy machines, fax machines, calculators, scanners, and shredders.
5. Ability to be professional and maintain a positive attitude and relationships with coworkers.
6. Ability to communicate with people outside the organization, representing the organization to customers, the public, government, and other external sources.

Duties and Responsibilities:

1. Timely and effective management of the individual caseload to include all assigned initial, concurrent, and discharge reviews.
2. Effectively communicate any deficiencies in chart/clinical documentation to the clinical team to ensure documentation is aligned with insurance company guidelines and standards.
3. Engage in strong advocacy for clients utilizing insurance, ensuring optimal length of stay.
4. Exemplify time management skills by scheduling peer reviews and appeals with available licensed providers as soon as possible, to minimize risk of uncovered days and/or lack of claim reimbursement.
5. Collaborate with the Director of Utilization Review and UR team on changes to LOC, authorization status, and complicated or time sensitive cases to better ensure optimal outcomes.
6. Keep accurate organizational notes and records for all actions completed related to the assigned caseload throughout all applicable spreadsheets.
7. Engage in any and all assigned training by the Director of Utilization Review to sharpen skill set, and increase knowledge of behavioral health utilization review.
8. Effectively relay any information shared by insurance care managers for collaboration of care to the appropriate AMFM clinical team.
9. Collaborate with the discharge planning team and clinical case managers by relaying any insurance information necessary to ensure a smooth and appropriate discharge plan for the individual assigned caseload.
10. Demonstrate a professional attitude and support the objectives of the facility philosophy through internal and external communications and interactions with all levels of staff, patients, community and referral sources.

Benefits for full time employees:

• Medical, Dental, and Vision plans through Anthem or Kaiser.
• FSA/HSA Accounts.
• Life/AD&D insurance through Anthem, 100% paid for by the employer.

Other benefits include:

• 401k plan with employer match.
• PTO, Self Care Day, and Floating Holiday.
• Educational Assistance Reimbursement Program.
• Employee Assistance Program.
• Health and Wellness Membership.

Application Instructions:

Please submit your resume directly through this online job posting to be considered. We thank you for your interest in joining our team.

AMFM Healthcare is committed to providing equal employment opportunities to all employees and applicants without regard to race, ethnicity, religion, color, sex (including childbirth, breast feeding and related medical conditions), gender, gender identity or expression, sexual orientation, national origin, ancestry, citizenship status, uniform service member and veteran status, marital status, pregnancy, age, protected medical condition, genetic information, disability, or any other protected status in accordance with all applicable federal, state and local laws.