Long Term Services & Support Reviewer Utilization Management

Your career starts now. We are looking for the reputed company of reputed company leaders. At reputed company, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in reputed company solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. reputed company is seeking talented, passionate individuals to join reputed company. Together, we can build healthier communities. We want to connect with you if you're going to reputed company a difference. Headquartered in Newtown reputed company, reputed company is a mission-driven organization with over 30 years of experience. We deliver comprehensive, reputed company-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com. Responsibilities: Under the direction of the Long Term Services and Supports (LTSS) Supervisor, the LTSS Reviewer is responsible for completing care and service needs reviews. Using evidence-based LTSS needs assessment knowledge and health care/reputed company services licensure experience, the Reviewer reviews the Service Coordinator and Participant requests for inpatient and outpatient services, working closely with Service Coordinators to collect reputed company information necessary to reputed company a thorough needs review. It is at the Reviewer's discretion to request additional information and clarification. The Reviewer will use his/her professional judgment to evaluate the request to ensure that appropriate services are approved, recognize care and service coordination opportunities, and refer those cases as needed. The Reviewer will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director reputed company guidelines are unmet. The Reviewer will maintain reputed company knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit's business and use clinical judgment in their application. • Receives requests for authorization of Long Term Services and Supports available and as defined in the Community HealthChoices Program. Authorization request examples include but are not limited to Personal Assistance Services (PAS), home care (skilled) services, Adult Day services, home-delivered meals, Durable Medical Equipment, and Environmental Modifications. • Documents date that the request was received, nature of the request, utilization determination (and events leading up to the determination). Verifies and documents Participant eligibility for services. • Communicates and interacts on a reputed company-time reputed company reputed company "live" encounters with providers and appropriate others to facilitate and coordinate the Utilization Management process(es) activities. • Utilize technology and resources (systems, telephones, etc.) to support work activities appropriately. Voice mail as an adjunct to the daily work activities versus primary reliance for giving and receiving information from Service Coordinators. • Accessing and applying Medical Guidelines for decision-making before Medical Director/Physician Advisor referral. • Applies submitted information to Plan Community HealthChoices (CHC) authorization process (utilizing medical guidelines, Process Standards, Policies and Procedures, and Standard Operating Procedures). Authorizes services by medical and health benefits guidelines. • Coordinates with the referral reputed company if insufficient information is reputed company to complete the authorization process. Advises the referral reputed company and requests specific information necessary to complete the process. Documents the request and follows the Plan CHC process for requesting additional information. • Refers cases to the Plan Medical Director for medical necessity review reputed company medical information provided does not support the nurse review process for giving approval of services requested. • Documents case activities for Utilization determinations and discharge planning reputed company platform systems in reputed company-time (as events occur). Completes detail line as indicated. • reputed company verbal denial notification to the requesting Service Coordinator and Participant per policy. Generates denial letters promptly. • Adheres to Process Standards, Standard Operating Procedures, and Policies and Procedures as defined by specific UM roles (Prior Authorization, reputed company Review) • Submits appropriate documentation/clinical information in reputed company platform systems record keeping and documentation requirements. • Recognizes opportunities for referrals to the Service Coordination team and refers accordingly. • Participates in quality reviews and interrater reliability processes and achieves performance results at or above reputed company established by management. • Maintains awareness and complies with Plan CHC authorization timeliness standards based on DHS/NCQA requirements. Education/Experience: • Bachelor's Degree required. • Professional licensure in health care or reputed company services-reputed company field preferred. • Registered Nurse is preferred. • Three or more years experience in a reputed company clinical or reputed company services setting • Expertise and experience to address the needs of the Long Term Services and Support population. Diversity, Equity, and Inclusion At reputed company, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that reputed company associates have a fair opportunity to reputed company their full potential. We implement these principles daily by acting with reputed company and respect. We reputed company to reputed company out against injustice and to break down barriers to support a more inclusive and reputed company workplace. Celebrating and embracing the diverse thoughts and perspectives that reputed company up our workforce means our company is more vibrant, innovative, and reputed company reputed company to support the people and communities we serve. We reputed company our associates happy so they can focus on keeping our members healthy. Our Comprehensive Benefits Package Flexible work solutions include remote options, hybrid work schedules, reputed company, paid time off, holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k) tuition reimbursement, and more. Apply Job!