Case Management/Utilization Review Manager

ABOUT US

Loretto Hospital is a safety-net hospital that serves more than 33,000 patients each year from Chicago’s Austin and surrounding communities. Established in 1923 as a not-for-profit community-focused healthcare provider, Loretto offers its community a unique patient-centered healthcare delivery system that promotes general wellness and education. The hospital staff are committed to providing the best possible medical care in a holistic, safe and comfortable resident environment. By empowering patients with knowledge and resources, Loretto Hospital strives to cultivate a culture of proactive medical management within the community, with the goal of increasing the quality of life for patients and community residents.

SUMMARY

We are looking for a dedicated UR/Case Manager to join our Case Management Department.  reporting to the Director of Case Management/Utilization Review, the UR/Case Manager supports members by coordinating services, tracking care progress, and promoting quality outcomes. This role focuses on effective care transitions, timely communication with providers, and ensuring services are aligned with health plan policies and patient needs

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Conduct initial and ongoing reviews to ensure appropriate utilization of healthcare eligibility, appropriateness, and coordination of behavioral health services
• Collaborate with licensed professionals to determine medical necessity and benefit coverage
• Coordinate with providers, members, and internal teams to ensure timely service delivery and care continuity
• Partner with licensed clinicians to support medical necessity determinations for mental health and substance use care
• Document and track member progress, care plans, and interventions within systems accurately and timely
• Facilitate communication and coordination among behavioral health providers, members, and support services
• Identify gaps in care and refer to appropriate clinical or community resources as needed
• Monitor ongoing care and progress and help manage transitions across settings (e.g., inpatient, residential, outpatient)
• Provide education and guidance to members regarding services, benefits, and resources
• Support transition of care activities, including discharge planning and follow-up coordination
• Adhere to regulatory, accreditation, and organizational guidelines\
• Other duties as assigned

COMPLIANCE RESPONSIBILITIES

• Understands and adheres to Loretto Hospital’s compliance standards as they appear in the Compliance Policy, Code of Conduct and Conflict of Interest Policy.
• Keeps abreast of all pertinent federal, state and Hospital regulations, laws, and policies as they presently exist and as they change or are modified.

 The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the personnel so classified.   For purposes of the American with Disabilities Act, “Job Duties” are essential job functions.

QUALIFICATIONS

Required:

• High School Diploma or GED required
• In Lieu of degree, 1–3 years of experience in healthcare coordination, case management, customer service, discharge planning and utilization review
• Familiarity with mental health and substance use service systems, including Medicaid or managed care environments
• Strong communication and organizational skills
• Proficient in case documentation and Microsoft Office tools
• Case Management Certification within 1yr of employment

Preferred:

• State of IL licensed RN/LPN preferred
• Associate or bachelor’s degree in healthcare, social services, behavioral health, social work, psychology or a related field
• Knowledge of Medicaid/Medicare, managed care, or health plan operations a plus

Core Competencies:

• Member-focused with a problem-solving mindset
• Comfortable navigating fast-paced, compliance-oriented environments
• Collaborative and respectful communicators across diverse teams
• Detail-oriented with sound judgment
• Ability to de-escalate emotionally charged situations and promote member engagement
• Exceptional communication and leadership skills, demonstrates good work ethic, and analytical skills
• Extensive knowledge of community resources.
• Demonstrates considerable knowledge of payor requirements and criteria sets.
•  Knowledge of regulatory requirements, including but not limited to, JCAHO, ACHC, IDPH and CMS.
  
  The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the personnel so classified.  For purposes of the American with Disabilities Act, “Job Duties” are essential job functions.

PHYSICAL DEMANDS

While performing the duties of this job, the employee is frequently required to sit, stand and walk as well as occasionally stoop, kneel, crouch or crawl. Using proper body mechanics, the employee may be expected to lift, pull, push or move patients and/or equipment.  Fine motor skills are required when using hands and fingers to handle, feel or reach.  Normal or corrected vision, hearing and ability to speak are necessary.  Specific vision abilities required include close vision, sharp eye focus and ability to distinguish colors.  There will be periods of stressful intense concentration with more than average pressure used in a variety of problem-solving situations.

WHY LORETTO

Competitive Compensation: Along with a competitive salary, Loretto Hospital offers a comprehensive, competitive benefits package including health, dental, vision, retirement savings plans, and paid time off.

Career Development: Loretto Hospital is a vibrant community of professionals dedicated to administering excellent patient care. Whether you are pursuing a career in allied health, support services, clinical or nursing support, or professional administration, Loretto Hospital is a tremendous place to grow as a health care professional.

Work Environment: As a not-for-profit, community-focused hospital, Loretto Hospital is truly a place where patients come first. We are seeking team members who not only support our mission, but who are customer service-driven and who desire to enhance the patient experience.