Inpatient Behavioral Health Utilization Review Specialist

This is an onsite position that will support initial and ongoing Utilization Review for our inpatient Adult and Child/Adol population. This position will work closely with both Case Management and the Intake departments.

We are offering two options for work hours. The final schedule will be determined by the best candidate's availability.

1. Sunday through Thursday 0700 to 1530. (Worked Sunday comes with a weekend Shift differential.)

or

2. Monday through Friday 0700 to 1530 but working one weekend a month is required. (Teammate will be compensated with two days off during the work weeks within that pay period to make up for worked weekend days. Worked weekend days also comes with a shift differential.)

Currently no holiday coverage is needed.

Pay Range

• Verifies patient's insurance to ensure accurate benefits and appropriate referral to providers for services. Assists patients in exploring financial options with our financial counselor if needed.
• Obtains detailed and thorough clinical information by reviewing assessments and clinical information found in the electronic medical record in order to obtain prior authorization for the following levels of care: Residential Treatment (RTC), Partial Hospitalization (PHP), and Intensive Outpatient Program (IOP).
• Completes prior authorization, concurrent reviews, discharge reviews, and retrospective reviews in a timely manner. The status of the authorization is documented in the electronic medical record. The date, time, and name of authorizing utilization reviewer at managed care company will be documented in the referral, per department standards. Explains and assists the patient in understanding their insurance benefits when information is available. Communicates with treatment team and patient regarding review status.
• Contacts patients via telephone if they do not arrive for programming. If patient is reached, the BH UR will discover why patient did not attend programming. If transportation is needed,the BH UR with explore transportation options and if appropriate, arrange transportation through Medical Transportation Management (MTM). This communication is documented in a telephone encounter.
• Utilizes clinical experience and skills in a collaborative process to asses appropriateness of treatment plans, apply evidence based standards and practice guidelines to treatment where appropriate.
• Initiates the denial/appeals process for non-certified care by collaborating with managed care reviewer and our physician. Arranges peer review with managed care physician and our program physician. Responsible for following through with all required documentation, paperwork, and communication with treatment team and patient.
• Responsible for obtaining pre-authorization for referrals sent to the APH Authorizations Pool. Outreach and coordinate patients start date for hospital based programming referrals.
• Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.

• None Required.

• Master's Degree in Social Work or related field.

• Typically requires 3 years of experience in assessments and utilization review in a managed care environment.

• Demonstrated leadership skills and ability to work independently.
• Must have excellent oral, written communication, and problem solving skills.
• Demonstrates working knowledge of reimbursement methods.
• Demonstrates working knowledge of the State of Wisconsin and Developmental Disabilities Code.
• Knowledge of state and federal mental health and chemical dependency regulations.

• Will frequently be required to lift up to 25lbs without assistance.
• Will occasionally be required to lift over 25lbs with assistance.
• May be exposed to the following hazards: mechanical, electrical, chemical, blood and body fluids. Must wear personal protective equipment as necessary.
• Must be able to sit, stand, and walk, throughout the workday.
• May be exposed to verbal or physical outbursts from patients and/or their families.

Our Commitment to You:

Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:

Compensation

• Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
• Premium pay such as shift, on call, and more based on a teammate's job
• Incentive pay for select positions
• Opportunity for annual increases based on performance

Benefits and more

• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program