Clinical Case Manager- Social Worker- Inpatient Behavioral Health

Salary: $32/hour - $48/hour  (Dependent upon experience)

Hours: Mon-Fri. No weekends on on-call.

Location: Albuquerque, NM (onsite)

Who we are:

Psychiatric Medical Care is one of the county's largest Behavioral Health Management companies. Why work with PMC? Because PMC works for you. At PMC, we strive to maintain a culture of kindness and accountability. We embrace diversity and inclusion and provide team member support. We encourage everyone at PMC to have a healthy work-life balance and bring their authentic selves to work every day.

Competitive Benefits:

• Free Dental & Free Vision
• Practically Free Medical Starting As Low As $20/Month
• Matching 401k
• Furthering Education Assistance 
• Employee Rewards, Assistance, & Referral Bonus Program

Essential Duties & Responsibilities

Utilization Review & Case Management

• Conducts reviews of patient admissions and continued hospital stays to ensure medical necessity.
• Identifies patients needing case management through admissions screening, chart review, and discharge planning meetings.
• Performs case management assessments and collaborates with interdisciplinary teams for discharge planning.
• Provides guidance to hospital staff regarding regulatory requirements, reimbursement policies, and utilization guidelines.
• Reviews observation admissions twice daily to determine appropriate utilization of services.
• Coordinates with the physician advisor on cases that do not meet acute care criteria.
• Ensures timely documentation and submission of third-party payer reviews and medical necessity determinations.

Patient & Staff Education

• Educates patients, families, and healthcare providers on the medical necessity process and regulatory requirements.
• Assists physicians in ensuring complete documentation of patient severity and required services.
• Clarifies treatment plans and collaborates with attending physicians to support appropriate care decisions.

Discharge Planning & Coordination

• Identifies potential delays in care and refers cases to the appropriate department or physician.
• Ensures referrals are completed for patient discharge needs, including home health, skilled nursing, DME, and social services.
• Coordinates incoming patient transfers and facilitates outgoing transfers when appropriate.
• Prepares cases for physician advisor review, ensuring proper documentation and clear presentation of concerns.

Regulatory Compliance & Quality Improvement

• Keeps current with regulatory requirements, including CMS, Medicare, Medicaid, TJC, and other compliance standards.
• Monitors and reports on hospital utilization data to improve efficiency and patient outcomes.
• Supports hospital and department mission and vision through best practices in case management.

Professional Development & Collaboration

• Attends department meetings and completes required education and competency training.
• Collaborates with nursing, medical staff, and ancillary departments to improve patient care processes.
• Serves as a resource for utilization and medical necessity issues across hospital departments.

Care:

• Provide case management to patients and families.
• Act as a point of contact for referral sources seeking patient admission to the Behavioral Health Unit and navigates accordingly.
• Participate in discharge planning, arrange follow-up care and develop mechanisms for exchanging appropriate information with sources outside the hospital in conjunction with the unit Social Worker.

Compliance:

• Assist with performance improvement activities within the department and participate in performance improvement activities. 
• Support the Behavioral Health Unit with insurance verification/pre-certification/certification necessary for maximized patient reimbursement within the designated hospital’s Utilization Management program.

Community:

• Serve as a resource person to healthcare professionals concerning community resources.
• Represent the Behavioral Health Unit at various scheduled events.

• Masters Degree In Social work - LCSW preferred, or LMSW - required
• Two or more years of previous experience in all aspects of social service or nursing with an emphasis on psychiatric work - preferred
• Excellent oral and written communication skills - required
• Verbal and written ability to give information and present ideas essential in administrative management - required
• Leadership ability, integrity, and initiative - required
• Ability to problem-solve effectively and positively handle stress - required
• BLS - required
• HWC training (will be provided) - required
• Basic computer knowledge - required