Behavioral Health Inpatient Utilization Review Specialist

• 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.

Licensure, Registration, and/or Certification Required:

• None Required.

Education Required:

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

Experience Required:

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

Knowledge, Skills & Abilities Required:

• 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.

Physical Requirements and Working Conditions:

• 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.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.