Major Responsibilities:

• Coordinates discharge planning, utilizing specialty services as needed. Monitors and ensures the discharge plans are completed in a timely manner. Facilitates calls to specialists as ordered (i.e. primary care physician, therapists). Works with families providing information and education services as needed.
• Reviews clinical/insurance information and completes data gathering if necessary. Explains estimated benefit information to patient and assist the patient in exploring financial options as needed.
• Obtains pre-authorization from managed care company. Performs ongoing concurrent reviews with payor source, maintaining written records of contacts. Investigates and negotiates different care options with the payor source/insurance company. Keeps the physician, treatment team, patient, family and financial counselor aware of review status.
• Initiates the denial/appeal process for non-certified care, following through with all required paperwork and communications.
• Assists with the development and maintenance of standards for case management across the Aurora Behavioral Health Services system.
• Facilitates communications between and negotiates with the patient/family, physicians, nurses, dietary, rehab, homecare, social services, and other disciplines that need to collaborate to provide care for the patient.
• Collaborates and coordinates efforts with treatment team members to complete the discharge plan in a timely manner. Attends and participates in treatment teams and unit meetings and may be assigned to lead and coordinate meetings as needed.
• 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:

• Registered Nurse license issued by the state in which the team member practices, or
• Social Worker license issued by the state of Wisconsin, or
• Professional Counselor license issued by the state of Wisconsin.

Education Required:

• Bachelor's Degree in Nursing, or
• Master's Degree in Social Work, or
• Master's Degree in Psychology, Counseling.

Experience Required:

• Typically requires 3 years of experience in behavioral health services that includes experiences in assessments, discharge planning 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.
• Demonstrated working knowledge of reimbursement methods and referral sources.
• Demonstrated working knowledge of the State of Wisconsin Mental Health 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 25 lbs. without assistance.
• Will occasionally be required to lift over 25 lbs. with assistance.
• May be exposed to the following hazards: mechanical, chemical, blood and body fluids.
• Must be able to sit, stand, walk, squat, bend, and reach above shoulders and twist.
• Ability to utilize proper de-escalation techniques when working with agitated patients.
• Demonstrates flexibility in an environment that requires the ability to multitask.
• Operates all equipment necessary to perform the job.
• Any exception to the above requirements must be demonstrated through Employee Health.

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.