Utilization Review Technician jobs in Milwaukee, WI

• Complete routine, frontline administrative work necessary- working with patients to complete all necessary forms, gathering demographic and insurance information, obtaining prior authorizations, entering information into the medical records system, and communicating with others to ensure patient insurance is set up appropriately in the electronic record and billing system. 
• Obtain prior authorizations and continued stay authorizations.
• Collaborate with internal and external stakeholders to support the patient and ensure high-quality, cost-effective care.
• Use nationally recognized, evidence-based guidelines to review appropriateness of admission and provision of care based on the patient’s clinical condition(s).
• Communicate with insurance companies and/or payer to obtain admission authorization and continued stay certification or recertification in a professional and timely manner. 
• Document utilization reviews and payer contact communication outcomes.
• Evaluate and facilitate concurrent and retrospective prior authorization denials, appeals, or payment issues until resolved to ensure proper reimbursement is received.
• Provide recommendations to providers and works with the healthcare team to ensure proper documentation utilization of care and to support medical necessity for hospital stay in the electronic medical record in accordance with regulatory standards.
• Serve as a resource to medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations, and documentation improvement opportunities.
• Communicate payer issues and medical necessity concerns with healthcare team to ensure appropriate care is provided. 
• Identify and escalate trends with insurance companies, denials, documentation/order requirements, or medical necessity concerns. Identifies and escalates quality concerns related to clinical care to leadership as appropriate.
• Actively contribute to and participates in utilization review and fiscal meetings or committees as assigned.
• Assists patients with referrals to the Moraine Lakes Consortium, or to the appropriate staff for insurance coverage.

1. Receives referrals of clients in need of mental health services. performs intake, and monitors client's behavior in relation to treatment plan goals and client's needs.
2. Maintains a caseload of individuals with personal social behavior problems including severe mental illness.
3. Responds appropriately to mental health emergency situations and utilizes crisis intervention techniques and procedures.
4. May screen requests for mental health services, determine appropriate services for client, and refer as necessary.
5. May perform medical necessity review that can include assessing appropriateness of treatment setting benefits advisory, prior authorizations, retro authorizations, and continuation of services advocacy.  
6. Provides counseling and supportive therapy to clients individually and/or in a group setting.
7. Provides case management services, coordinating services with various agencies including public and private payors and benefit entities in order to ensure on?going assessment and follow?through of treatment plans.
8. Maintains appropriate documentation of all client contacts, consultation with other professionals, and documents any changes on treatment plan; intervenes when appropriate in response to changes.
9. Participates in various meetings, staffings, and in?services; may provide consultation to other professionals and paraprofessionals.
10. Conducts assessments of client needs through interviews, collateral contacts, and other investigations; develops a casework plan with clients.
11. Provides information to family regarding a client's diagnosis and treatment and provides supportive counseling to family as needed.
12. Acts as a departmental liaison, providing casework direction, and supervision to providers of contracted services.
13. Provides recommendations and testimony in court as to clients' mental health status and submits appropriate documentation.
14. Establishes and maintains effective working relationships with clients and their families, service providers, colleagues, payors, benefit entities, and the general public.
15. Prepares and presents detailed oral and written reports.
16. Documents case assessment, treatment planning, and progress notes in the written record.
17. Complies with State and Federal program requirements.
18. Provides payer services; reviews and verifies all contracted service provider invoicing.
19. Performs emergency government duties as assigned in event of Waukesha County Emergency Government declaration.
20. Performs other duties as required.
    
    

QUALIFICATIONS
Essential Knowledge and Abilities 

1. Considerable knowledge of mental health disorders and treatment methods.
2. Considerable knowledge of case management principles and methods.
3. Considerable knowledge of the principles, practices, methods, and techniques used in the treatment of mental health disorders.
4. Considerable knowledge of human services and health resources in the community.
5. Considerable knowledge of Wisconsin State Statutes Chapters 51, 54, 55.
6. Working knowledge of techniques to identify clients with substance use problems.
7. Working knowledge of electronic health record, computerized department program software, internet access, database, spreadsheet, and word processing programs.
8. Working knowledge of confidentiality statutes and requirements, including the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
9. Working knowledge of public and private payor contracts, benefits, authorization requirements, and clinical criteria in relation to clinical programs.
10. Ability to utilize word processing, database, and spreadsheet programs.
11. Ability to establish and maintain effective working relationships with clients and their families, service providers, colleagues, payors, benefit entities, and the general public.
12. Ability to effectively interact with sensitivity with persons from diverse cultural, socioeconomic, educational, racial, ethnic, and professional backgrounds, and persons of all ages and lifestyles.
13. Ability to respond appropriately to mental health emergency situations and procedures.
14. Ability to communicate effectively, orally, and in writing.
15. Ability to communicate with clients who have mental health disorders.
16. Ability to interpret mental illness and its diagnosis and treatment to clients and families.
17. Ability to provide skilled treatment to clients with social and behavioral problems.
18. Considerable knowledge with regard to assessing client risk.

You must meet these minimum Training and Experience requirements:

1. For work assignments in utilization review and benefit verification the following may be substituted:
   a.    Bachelor’s degree from a recognized college or university with a major in sociology, social work, psychology, or a closely related field.
   OR
   Graduation from a recognized nursing program with active Registered Nurse licensure.
   b.    Two years of full-time experience in a health or human service field.