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Under the general supervision of the Service Utilization Supervisor, this position manages service authorizations in the Lakeland Care electronic member record system. This position supports Interdisciplinary Teams (IDT) by ensuring authorizations are accurately completed based on IDT Resources Allocation Decision (RAD) determinations, maintaining compliance with policy and documentation requirements. As a subject matter expert, this position reviews service guidelines, verifies provider information, monitors quality and compliance, coordinates with claims as needed, and provides resources to IDT staff on best practices to ensure accurate authorizations, documentation, and claims processing.

Essential Competencies:

• Timely and accurately enter and modify service authorizations into the electronic member record system, thereby reducing risk for duplicate claims, missing claims, or incorrectly coded claims. Review service guidelines, coordinate with claims on payment accuracy, and ensure authorizations align with policy requirements.
• Conduct routine authorization audits and remediate any findings to ensure accuracy of service authorizations and appropriate payment of claims.
• Contribute to ongoing quality improvement within the service authorization entry process, including auditing and analysis.
• Conduct quality reviews of required documentation and provider information (e.g., SNF HIPPS codes, TIN changes) to prevent delays in member services.
• Respond constructively to emotional situations, high pressure, and conflict.
• Demonstrate emotions appropriate to the situation and continue to perform steadily and effectively.
• Convey messages concisely and advise others regarding an appropriate course of action.
• Teamwork is essential at all times.
• Identify obstacles and address problems cooperatively as they occur.
• Utilize and apply relevant Standard Practice Codes (SPCs) to ensure appropriate and accurate claims processing.
• Provide guidance and share resources to ensure consistent adherence to policies, correct coding practices, and best practice standards for designated services.
• Review organizational data and analyze utilization trends to bring forward for Care Management practice review.

• Associate Degree or specialized training in Medical Records, Medical Coding, other related field preferred, or equivalent combination of education and experience (includes knowledge, skills, and abilities).
• One (1) year of experience in medical billing or insurance authorization preferably in Family Care or health care setting. 
• Strong understanding of service authorization guidelines, policies and procedures.
• A strong understanding of Lakeland Care’s electronic member records system is necessary to ensure that all authorizations are correctly entered.
• Knowledge of medical terminology and/or experience with CPT, ICD-9 and ICD-10 coding.
• Knowledge of Medicare, Medicaid, Family Care preferred.
• Excellent verbal and written communication; ability to respectfully and effectively communicate with internal and external partners.
• Attention to detail and the ability to critically think in a fast-paced environment.
• Computer literate including experience with spreadsheets, MS Word, e-mail, and the internet.
• Current driver’s license, acceptable driving record and proof of adequate insurance required.

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Lakeland Care is a Wisconsin-based non-profit organization that focuses on creating a world we all want to live in. With long-standing roots as a managed care organization (MCO), we provide long-term care services to eligible elders and individuals with physical and intellectual or developmental disabilities. Currently we serve members in 22 counties and have 11 offices throughout the Central to North East region of Wisconsin.

Our Mission

Empowering individuals. Strengthening communities. Inspiring futures.

Our Vision

To create a world we all want to live in.

Our Core Values

Kindness – We believe kindness is always possible and that no compassionate act is ever wasted.

Inclusion – We believe that open hearts and open minds are the only path to a brighter future.

Trust – We believe that honesty is still in style and that promises still have power.

We are an equal employment opportunity employer functioning under an Affirmative Action Plan. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law. We are an organization that participates in E-Verify.