Case Manager Detox Withdrawal Management Unit

Job Summary

Responsible for utilization review and clinical chart review to ensure medical necessity, appropriate level of care, regulatory compliance, and optimal reimbursement for substance use disorder inpatient cases. The position is an essential part of the withdrawal management unit’s treatment team. The position reports to the nurse manager.

Essential Functions

Utilization Review & Insurance Authorization

• Performs initial, concurrent, and retrospective chart reviews to determine medical necessity and appropriateness of admission and continued stay.

• Obtains and maintains prior authorizations for detoxification admissions, as needed.

• Conducts continued reviews with third-party payers in accordance with payer guidelines.

• Submits required clinical documentation to payers within required timelines.

• Responds to insurance level-of-care inquiries and review agency requests.

• Participates in peer-to-peer coordination as needed to support medical necessity determinations.

Documentation & Compliance Review

• Reviews medical records to ensure documentation supports medical necessity, ASAM level of care. and inpatient continued stay criteria.

• Identifies documentation deficiencies and communicates findings to providers for correction or clarification.

• Monitors length of stay against approved days and proactively initiate re-authorization processes.

• Assists in denial prevention strategies and prepares appeal documentation when required.

Data Tracking & Reporting

• Maintains utilization tracking logs, authorization status reports, and payer communication documentation.

• Tracks denials, pending cases, and payer response timelines.

• Provides data reports related to LOS, payer mix, denial trends, and authorization metrics as requested by leadership.

• Participates in daily treatment team meetings.

Regulatory & Policy Compliance

• Maintains working knowledge of Medicare, Medicaid, and third-party insurance regulations related to SUD services.

• Ensures adherence to hospital policies regarding utilization review and reimbursement standards.

• Participates in audits related to utilization management and payer compliance.

• Demonstrates a working knowledge of hospital-based joint commission standards.

Other Duties

This job description does not aim to provide a comprehensive list of all duties, responsibilities, or qualifications linked to the position. The management retains the right to change, add, or eliminate duties and responsibilities at any time, with or without advance notice.

Minimum Education/Certifications

• High School Diploma or Equivalent

Minimum Work Experience

• At minimum of 2 years of experience in a clinical or administrative healthcare role (e.g., Compliance/ Quality Assurance Specialist, Patient Access, Case Management, Office Manager).
• Prior work experience in Substance Abuse Treatment healthcare organization.
• Minimum of 1 year of case management or utilization review experience.
• Experience leading audits with regulatory agencies.
• Clear understanding of medical terminology and common diagnoses.
• Effective communication, organizational, and time management abilities.
• Ability to multitask in a fast-paced environment working amongst and interdisciplinary team.
• Experience working with electronic medical records (EMR) systems.
• Understanding of privacy, ethics, and professional boundaries.

Preferred:

• Substance Use Treatment clinical experience.
• Background in performing chart audits.
• RN or Master’s Prepared Clinician

Position Type/Expected Hours of Work:

• Onsite position.
• Full-time 37.5-hour work week with occasional weekend or holiday coverage as needed.

Physical Requirements:

Position requires prolonged periods of sitting and use of a computer and screen viewing throughout the working day.

Positions will be required to stoop, bend, lift, and carry items weighing up to 25 pounds.