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Authorization Utilization Review Jobs in Wisconsin

Acadia Healthcare

RN - Admissions Acute

Madison, WI · On-site

$72K - $98K/yr

... utilization review processes to assure continuity for the most appropriate level of care for ... Perform insurance benefit verifications and secure initial pre-authorization for treatment and ...

Acadia Healthcare

RN - Admissions Acute

Madison, WI · On-site

$73K - $99K/yr

... utilization review processes to assure continuity for the most appropriate level of care for ... Perform insurance benefit verifications and secure initial pre-authorization for treatment and ...

Eden Senior Care

MDS Coordinator

Oshkosh, WI · On-site

$80K - $90K/yr

New admission authorizations, updates, communication with family/insurance providers, communication ... Run Utilization Review Meetings and ensure PDPM scores and rates are validated * Review and Educate ...

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Authorization Utilization Review information

What are the key skills and qualifications needed to thrive as an authorization utilization review specialist?

To thrive as an Authorization Utilization Review Specialist, you need a solid understanding of medical terminology, healthcare regulations, and insurance policies, often backed by a clinical background or relevant certifications. Familiarity with utilization management software, electronic health records (EHR), and payer portals is typically required. Strong attention to detail, analytical thinking, and effective communication are vital soft skills for coordinating with providers and payers. These skills ensure accurate authorization decisions, regulatory compliance, and efficient patient care coordination.

What are some common challenges faced by professionals in authorization utilization review roles, and how can they be addressed?

Professionals in Authorization Utilization Review often encounter challenges such as managing high caseloads, navigating complex insurance guidelines, and ensuring timely communication with providers and patients. Staying organized and up-to-date with evolving payer requirements is essential to avoid delays or denials. Building strong collaboration with clinical teams and leveraging electronic health record systems can help streamline workflows and improve efficiency in the review process.

What is the difference between Authorization Utilization Review vs Claims Reviewer?

AspectAuthorization Utilization ReviewClaims Reviewer
CredentialsTypically requires healthcare or insurance-related certifications, such as RN, CPC, or licensed healthcare professionalsOften requires similar credentials, focusing on insurance policies and claims processing
Work EnvironmentHospitals, insurance companies, healthcare facilitiesInsurance companies, third-party administrators, healthcare organizations
Industry UsageUsed to assess medical necessity before approving servicesUsed to evaluate claims for payment accuracy and compliance

Authorization Utilization Review and Claims Reviewer roles both involve insurance and healthcare knowledge, but Authorization Utilization Review focuses on pre-authorization of services, while Claims Review centers on post-service claims assessment. Understanding these differences helps clarify career paths and job expectations in healthcare insurance.

What is authorization utilization review?

Authorization Utilization Review is a process used by healthcare organizations and insurance companies to assess the medical necessity and appropriateness of medical services before they are provided. The main goal is to ensure that patients receive care that is effective, efficient, and covered by their health plan. This review typically involves evaluating patient records, treatment plans, and provider requests to decide if the requested services meet established guidelines. By doing so, it helps control healthcare costs and ensures quality care for patients.
What are popular job titles related to Authorization Utilization Review jobs in Wisconsin? For Authorization Utilization Review jobs in Wisconsin, the most frequently searched job titles are:
What job categories do people searching Authorization Utilization Review jobs in Wisconsin look for? The top searched job categories for Authorization Utilization Review jobs in Wisconsin are:
Authorization Utilization Review jobs near you
Infographic showing various Authorization Utilization Review job openings in Wisconsin as of August 2026, with employment types broken down into 1% As Needed, 83% Full Time, 13% Part Time, and 3% Contract. Highlights an 89% Physical, 3% Hybrid, and 8% Remote job distribution.

RN - Admissions Acute

Acadia Healthcare

Madison, WI • On-site

$72K - $98K/yr

Full-time

Posted 10 days ago

Acadia Healthcare rating

6.2

Company rating: 6.2 out of 10

Based on 190 frontline employees who took The Breakroom Quiz

701st of 887 rated healthcare providers

Job description

Overview
Shifts Available:
Nights: 10:00p - 8:30a
4/10s with weekend rotation
Are you prepared for the impact you can make as an RN in Behavioral Health? We are looking for Registered Nurses at Shorewood Behavioral Health.
This BRAND NEW state-of-the-art 120-bed behavioral healthcare hospital is located in Madison, WI. Shorewood Behavioral Health Hospital will specialize in providing comprehensive acute and outpatient psychiatric care for adolescents, adults, and seniors dealing with mental health and substance use disorders. The hospital will offer Partial Hospitalization Programs (PHP), Intensive Outpatient Programs (IOP), and Electroconvulsive Therapy (ECT), along with the development of specialized programs to meet community need.
PURPOSE STATEMENT:
Clinical professional is responsible for facilitating admissions, clinical intake assessments, and utilization review processes to assure continuity for the most appropriate level of care for patients and their benefit/resource utilization.
Responsibilities
  • Review medical documentation for all admissions, complete medication reconciliation, and obtain admission orders from physicians.
  • Facilitate emergency transfers for patients presenting with emergency medical conditions outside of the facility's capabilities.
  • Review referrals from hospitals, facilities, and other community agencies for medical and behavioral acuity and respond within facility policy timeframes.
  • Respond to inquiries about the facility and provide appropriate recommendations.
  • Conduct assessments to determine the appropriate level of care within the facility.
  • Collaborate with other facility medical and psychiatric personnel to ensure appropriate recommendations and admissions.
  • Facilitate admissions process for incoming patients including assessment, consent, and inventory of patient belongings.
  • Perform insurance benefit verifications and secure initial pre-authorization for treatment and admission.
  • Monitor patient status throughout the admissions process in accordance with facility policy and/or physician orders.
  • Utilize multiple web-based programs to track and review referrals.
  • Communicate projected admissions to designated internal representatives promptly.
  • Ensure all clinical information from referral sources or patients (including medical comorbidity information) is received, when possible, prior to patient admission.
  • Schedule (when applicable) and complete pre-admission assessments, consult with the admitting physician and communicate disposition recommendations to the patient or their family.
  • Possess skill in preparing and maintaining appropriate medical record documentation that will result in authorization at the level of care being requested of the payor.
  • Complete initial pre-authorization for treatment and admission prior to admission, when possible, and within payor timeframe guidelines.
  • Admit the patient to the registration and accounting system. Complete all admission and consent forms with the patient.
  • Demonstrate a positive, empathetic, and professional attitude toward customers always. When patient needs are not met, acknowledge and work to resolve complaints. Recognize that patient safety is a top priority.
  • When a patient's needs are not met, acknowledge and work to resolve complaints. Recognize that patient safety is a top priority.
  • Coordinate care for patients who are not being admitted and ensure that they receive appropriate follow-up care and referrals.
  • Demonstrate a sense of urgency related to the importance of patient safety and provide excellent customer service.
  • Responsible for conducting safety checks and ensuring that supervision is conducted at 15-minute intervals, as noted in special precautions, or in accordance with individualized supervision guidelines as needed.

OTHER FUNCTIONS:
  • Perform other functions and tasks as assigned.

Qualifications
EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:
  • Minimum of Associate's degree in Nursing.
  • Minimum one year of experience working with individuals in a clinical or observational capacity, preferably within the area of specialty for the hiring facility.

LICENSES/DESIGNATIONS/CERTIFICATIONS:
  • Clear and active nursing license in the state.
  • CPR and de-escalation/restraint certification required (training available upon hire and offered by facility).
  • First aid may be required based on state or facility

We are committed to providing equal employment opportunities to all applicants for employment regardless of an individual's characteristics protected by applicable state, federal and local laws.
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About Acadia Healthcare

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Acadia Healthcare is a leading provider in the healthcare and hospital industry, based in Franklin, Tennessee, United States. The company is recognised for its commitment to creating a behavioural health network that provides accessible, high-quality treatment options for individuals suffering from mental health issues, addiction, eating disorders, and PTSD. Acadia Healthcare was founded in 2005, with the mission to create a world-class organization that sets the standard of excellence in the treatment of specialty behavioural health and addiction disorders.

Industry

Hospitals

Company size

10,000+ Employees

Headquarters location

Franklin, TN, US

Year founded

2005

Social media

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