Role Description Join our award winning culture as we serve members in your area! 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. - 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. Qualifications - 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. Company Description 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.

• Apply specialized, clinical knowledge of hospital partners: categorize, code, summarize, interpret and calculate registry/case information from nuanced, patient medical records. • Ensure quality submission of all data in specified registries or measure data repositories, maintaining a high accuracy threshold. • Prioritize, organize, and meet tight deadlines for multiple concurrent tasks and team requests; uses tact and judgment to manage expectations, flag obstacles, and propose solutions in a timely manner. • Navigate new technical systems: electronic medical records (EMR) and registry/case entry tools; use team resources to troubleshoot technical issues with systems and applications with a focus on solutions. • Contribute to team best practices, data dictionaries, abstraction guidelines, and other business rule documents; identifies process improvement opportunities to help streamline tasks and processes. • Keeps up to date on mandated regulatory/publicly reported data requirements as specified by federal, state, payer, and other agencies. • Any or other additional responsibilities as assigned

Role Description Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. Location: This position is full-time (40 hours/week) Monday through Friday in a typical office environment. This role is remote position for South Carolina, Georgia, North Carolina or Alabama. What You'll Do: - Perform medical claim reviews for one or more of the following: - Claims for medically complex services - Services that require preauthorization/predetermination - Requests for appeal or reconsideration - Referrals for potential fraud and/or abuse - Correct coding for claims/operations - Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. - Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. - Monitor process’s timeliness in accordance with contractor standards. - Document medical rationale to justify payment or denial of services and/or supplies. - Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. - Participate in quality control activities in support of the corporate and team-based objectives. - Provide guidance, direction, and input as needed to LPN team members. - Provide education to non-medical staff through discussions, team meetings, classroom participation, and feedback. - Assist with special projects and specialty duties/responsibilities as assigned by management. Qualifications - Associate's in a job related field - Graduate of Accredited School of Nursing. - Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC). - 2 years clinical experience. - Working knowledge of word processing software. - Ability to work independently, prioritize effectively, and make sound decisions. - Good judgment skills. - Demonstrated customer service and organizational skills. - Demonstrated oral and written communication skills. - Analytical or critical thinking skills. - Ability to handle confidential or sensitive information with discretion. - Microsoft Office. Benefits - 401(k) retirement savings plan with company match - Subsidized health plans, dental and vision coverage - Life insurance - Paid Time Off (PTO) - Nine paid holidays - On-site cafeterias and fitness centers in significant locations - Wellness programs and a healthy lifestyle premium discount - Tuition assistance - Service Recognition Company Description We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

Role Description This position is responsible for processing all release of information (ROI) requests in a timely, efficient, and accurate manner while delivering exceptional customer service. The Associate must safeguard patient privacy at all times by ensuring that only authorized individuals access medical records, and that all information is released in accordance with the request, applicable authorization, company policies, and HIPAA regulations. This role also provides support to team members and management by serving as a subject matter expert, trainer, and escalation point. The Lead plays a key role in ensuring high-quality output and operational consistency by mentoring colleagues, assisting with work assignments, and monitoring quality and productivity metrics. Essential Functions - Processes ROI requests from facilities timely, accurately, and in accordance with established procedures and quality standards. - Validates requests and authorizations for medical record releases based on company policy and legal guidelines. - Performs quality checks to ensure accuracy, confidentiality, and correct billing of all released records. - Maintains equipment in excellent working condition. - Delivers outstanding customer service by being attentive, respectful, and responsive to client needs proactively identifying and resolving concerns. - Maintains a clean, professional appearance and complies with the company dress code. - Maintains up-to-date knowledge of applicable state laws and fee structures. - Works within assigned scope and is flexible in accepting additional assignments or account coverage during backlogs. - Complies with client site policies and procedures, including HIPAA, state/federal regulations, and labor laws. - Handles confidential information with integrity and professionalism while ensuring efficient, accurate record release. - Provides onboarding and training services for new employees. - Supports customer service by managing escalations and resolving issues. - Communicates regularly with supervisors and managers regarding quality, client concerns, or system issues. - Assists with administrative tasks such as queue management and work assignments. - Produces reports and metrics as requested. Qualifications - High School Diploma (GED) required; degree preferred. - Minimum 3 years' ROI fulfillment experience with Sharecare HDS or 4 years of external ROI experience required. - Advanced knowledge of multiple EMR platforms and ROI request types. - Strong organizational and multitasking skills essential. - Proficiency in Microsoft Office applications. - Strong documentation, communication, and customer service skills. - Demonstrated ability to manage time effectively and meet task deadlines. - Willingness to learn programs and processes quickly. - Self-motivated, dependable, and able to work independently or as part of a team. - Proven ability to maintain productivity, utilization, and quality performance standards. - Strong interpersonal and problem-solving skills. - Serve as the Subject Matter Expert (SME) for assigned customer accounts, demonstrating strong skills in documentation, communication, and organization. - Demonstrates strong leadership abilities. - Ability to assist with onboarding and training of new employees. - Ability to monitor production, utilization, and quality of employees. - Ability to assist with adhering to customer SLAs, including turnaround time (TAT). Physical Requirements - Ability to sit or stand for extended periods. - Physical ability to lift and carry up to 25 lbs. - Manual dexterity is sufficient for long periods typing, writing, and handling documents. - Visual acuity to read documents and use a computer monitor. - Clear speaking and hearing ability for communication. - Adequate hand-eye coordination and sensory abilities for job-related tasks. Information Governance Accountabilities - Understand the organization's information governance program and the role's responsibilities. - Participate in required education and compliance training. HIPAA/Compliance - Maintain the confidentiality of patient and client information. - Comply with HIPAA standards and all relevant corporate integrity and security obligations. - Report any unethical, fraudulent, or illegal behavior. - Maintain current HIPAA certification annually.