Long Term Services & Support Reviewer Utilization Management, RN at AmeriHealth Caritas

About the position

The Long Term Services & Support Reviewer for Utilization Management at AmeriHealth Caritas plays a crucial role in ensuring that individuals receive the appropriate care and services they need. This position is primarily responsible for conducting comprehensive reviews of care and service needs under the guidance of the LTSS Supervisor. The Reviewer utilizes their expertise in evidence-based LTSS needs assessment and healthcare/social services licensure to evaluate requests for inpatient and outpatient services. This involves close collaboration with Service Coordinators to gather all necessary information for a thorough needs review. The Reviewer has the discretion to request additional information and clarification as needed, applying their professional judgment to ensure that services are appropriately approved and that care coordination opportunities are recognized and referred as necessary. In this role, the Reviewer will apply medical health benefit policies and medical management guidelines to authorize services, identifying cases that require referral to the Medical Director when guidelines are not met. It is essential for the Reviewer to maintain current knowledge of relevant laws, regulations, and policies that impact the organization??s operations, using clinical judgment in their application. The position involves receiving requests for authorization of Long Term Services and Supports as defined in the Community HealthChoices Program, which may include Personal Assistance Services, home care services, Adult Day services, home-delivered meals, Durable Medical Equipment, and Environmental Modifications. The Reviewer is responsible for documenting the date of request receipt, the nature of the request, and the utilization determination, as well as verifying and documenting participant eligibility for services. Effective communication is key, as the Reviewer interacts in real-time with providers and other stakeholders to facilitate the Utilization Management processes. Utilizing technology and resources effectively is also a critical aspect of this role, ensuring that information is communicated promptly and accurately. The Reviewer must adhere to established Process Standards, Standard Operating Procedures, and Policies and Procedures, while also participating in quality reviews and achieving performance results that meet or exceed management thresholds. Overall, this position is vital in maintaining the integrity and efficiency of the care management process within the organization.

Responsibilities
?? Complete care and service needs reviews under the direction of the LTSS Supervisor.
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?? Review Service Coordinator and Participant requests for inpatient and outpatient services.
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?? Collect necessary information to perform thorough needs reviews in collaboration with Service Coordinators.
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?? Evaluate requests using professional judgment to ensure appropriate services are approved.
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?? Apply medical health benefit policy and medical management guidelines to authorize services.
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?? Identify and refer cases to the Medical Director when guidelines are unmet.
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?? Maintain knowledge of laws, regulations, and policies relevant to the organizational unit's business.
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?? Document the date of request receipt, nature of the request, and utilization determination.
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?? Verify and document Participant eligibility for services.
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?? Communicate in real-time with providers and others to facilitate Utilization Management processes.
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?? Utilize technology and resources to support work activities effectively.
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?? Access and apply Medical Guidelines for decision-making before referral to Medical Director/Physician Advisor.
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?? Authorize services according to medical and health benefits guidelines.
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?? Coordinate with referral sources if insufficient information is available to complete the authorization process.
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?? Advise referral sources and request specific information necessary to complete the process.
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?? Document case activities for Utilization determinations in real-time.
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?? Provide verbal denial notifications to Service Coordinators and Participants as per policy.
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?? Generate denial letters promptly and adhere to Process Standards and Policies.
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?? Submit appropriate documentation in enterprise platform systems for record keeping.
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?? Recognize opportunities for referrals to the Service Coordination team and refer accordingly.
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?? Participate in quality reviews and achieve performance results at or above management thresholds.
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?? Comply with Plan CHC authorization timeliness standards based on DHS/NCQA requirements.

Requirements
?? Bachelor's Degree in a health care or social services-related field.
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?? Professional licensure in health care or social services-related field.
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?? Three or more years of experience in a related clinical or social services setting.
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?? Expertise and experience in addressing the needs of the Long Term Services and Support population.

Nice-to-haves

Benefits
?? Flexible work solutions including remote options and hybrid work schedules.
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?? Competitive pay and paid time off.
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?? Holidays and volunteer events.
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?? Health insurance coverage for you and your dependents on Day 1.
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?? 401(k) plan with company match.
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?? Tuition reimbursement.

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