Behavioral Health Utilization Management Reviewer

Group Health Cooperative of South Central Wisconsin. BETTER TOGETHER

This is a full-time position at 40 hours per week.

Using a collaborative process, the Behavioral Health (BH) Utilization Management Reviewer will review, plan, implement, monitor, and evaluate the options and services required to meet an individual's health needs, using communication and available resources to promote quality, and cost-effective outcomes. They help identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in a timely and cost-effective manner while maintaining quality of care.

The BH Utilization Management Reviewer is responsible for evaluating the medical appropriateness, quality, and cost effectiveness of proposed services in accordance with established criteria. This review activity may be conducted prospectively, concurrently, or retrospectively and in collaboration with patients, practitioners, and other professionals. They play a key role in collaborating with Case Managers on a continuous basis when a member is being case managed. They offer support and serve as a resource for Care Management Associates and other staff. The work is carried out under the general direction, guidance, and supervision of the Care Management Department Manager.

GHC-SCW is a quality driven cooperative built on collaboration, community involvement, innovation, and belonging. In dedication to the health and well-being of our employees, we offer a comprehensive benefits package that includes health and dental insurance, along with paid short-term disability, long-term disability, and life insurance. Additional benefits include a flexible spending account, employee assistance programs, tuition reimbursement, pet insurance, eyewear discounts, and more. Check us out by clicking on Many Talents, One Mission! The Benefits of Working at GHC-SCW.

Job Specific Minimum Qualifications

1. Graduation from an NLN accredited school of Nursing, Bachelor's degree is preferred OR Bachelor's or Master's degree from an accredited College or University in Social Work or Social Welfare is required.
2. Valid current license to practice in the State of Wisconsin as a Registered Nurse OR License to practice in the State of Wisconsin as a Social Worker at the appropriate level consistent with education and training. (CSW, CISW, CAPSW, or LCSW) required.
3. Knowledge of utilization principles, methods, and techniques with experience in primary and/or acute care management. Ability to follow established criteria, policies, and procedures utilized in medical reviews.
4. Ability to keep abreast of legal and regulatory changes affecting the delivery of care.
5. Experience with or basic knowledge of health plan benefits.
6. Excellent oral and written communication skills required. Ability to communicate effectively in person, in groups, and on the telephone.
7. Ability to be culturally sensitive and to work with a diverse patient population.
8. Knowledge of and ability to use computer-based applications such as MS Office, (word processing, email, calendar).
9. Knowledge of and/or ability to learn and effectively use electronic medical and insurance record systems. Experience with EPIC systems is desirable but not required.
10. Ability to maintain patient and organizational confidentiality required. Knowledge of or ability to learn HIPAA requirements.
11. Knowledge of medical records and appropriate documentation requirements.
12. Planning and scheduling skills.
13. Ability to apply clinical criteria to analyze requests.
14. Self-motivation and self-direction required; capable of working independently with limited direct supervision.
15. Excellent customer service skills. Ability to work effectively with all levels of staff, practitioners, internal departments, external parties and members.
16. Strong organizational skills.
17. Ability to pay attention to details.
18. Ability to function as a team player.
19. Possession of a valid Wisconsin Driver License with good driving record. Employee must be able to provide own transportation to various worksites.
20. Ability to sit, stand, walk, and drive on a regular basis required.

The incumbent knows and abides by all Group Health Cooperative of South-Central Wisconsin (GHC-SCW) organizational and departmental policies, sets personal standards and strives for high quality work in completing assignments, performs job duties in a timely manner, and represents the organization in a positive manner. The incumbent understands our Mission, Vision, and Common Values (stated below) and is committed to promote these values in behavior and attitude.

Our Mission Statement: We partner with members and the communities we serve to maximize health and well-being.

Our Vision: As a local, not-for-profit, member-owned Cooperative, we are the most trusted resource for lifelong health and well-being in the communities we serve.

Our Values

• We are a not-for-profit Cooperative
• We are member-centered
• We are equitable and inclusive
• We are quality-driven
• We are innovative
• We are community involved

We believe:

Healthcare is a human right.

In treating all people with dignity and respect.

There is strength in diversity.

Equity celebrates our humanity.

We are better together.

Group Health Cooperative of South Central Wisconsin is proud to be an equal opportunity employer. GHC-SCW considers candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

• Administration - 1265 John Q. Hammons Drive, 1265 John Q. Hammons Dr. , Madison, Wisconsin, United States of America