Long Term Services & Support Reviewer Clinical

Amerihealth Caritas•,

2d•Remote

About The Position

AmeriHealth Caritas is seeking talented, passionate individuals to join our team. We are a mission-driven organization with more than 30 years of experience, delivering comprehensive, outcomes-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. This role is 100% remote and requires access to a reliable high-speed internet connection (50 Mbps download/5 Mbps upload).

Requirements

Bachelors degree required.
Registered nurse required.
UM experience required.
3 or more years of experience in a related clinical or social services setting.
Access to a reliable high-speed internet connection (50 Mbps download and 5 Mbps upload) for remote work.
Must be seeking candidates in Michigan.

Nice To Haves

Expertise and experience in addressing the needs of the Long Term Services and Support population.

Responsibilities

Completing care and service needs reviews using evidence-based LTSS needs assessment knowledge and clinical/social services experience.
Reviewing Service Coordinator and Participant requests for outpatient services.
Working closely with Service Coordinators to collect all information necessary to perform a thorough needs review.
Sending requests for additional information and/or requesting clarification.
Evaluating requests to ensure appropriate services are approved, recognizing care and service coordination opportunities, and referring cases as needed.
Applying professional and clinical judgment, clinical policies, and medical management guidelines to authorize or deny services.
Maintaining current license, knowledge, and understanding of relevant laws, regulations, and policies.
Handling denials for LTSS services based on professional judgment and discretion.
Understanding member’s ongoing medical conditions, triaging member needs to other appropriate specialty programs, and working with HCBS services coordinator to ensure the plan of care reflects medical needs.
Receiving requests for authorization of Long Term Services and Supports available and as defined in the Michigan Tailored benefit plan (e.g., Personal Assistance Services, home care, Adult Day Services, Home Delivered Meals, Durable Medical Equipment, Environmental Modifications).
Documenting the date of request, nature of the request, and utilization determination.
Verifying and documenting Participant eligibility for services.
Communicating and interacting in real-time with providers and appropriate others to facilitate and coordinate Utilization Management processes.
Utilizing technology and resources to support work activities.
Accessing and applying Medical Necessity Guidelines for decision-making.
Applying submitted information to the Michigan Tailored Plan authorization process.
Coordinating with the referral source if insufficient information is available and requesting specific information.
Documenting case activities for Utilization determinations and discharge planning in enterprise platform systems in a real-time manner.
Providing verbal denial notification to the requesting Service Coordinator and Participant and reviewing/generating denial letters.
Adhering to Process Standards, Standard Operating Procedures, and Policies and Procedures.
Submitting appropriate documentation/clinical information in enterprise platform systems.
Recognizing opportunities for referrals back to the Service Coordination team and referring accordingly.
Participating in Quality Reviews and Inter Rater Reliability processes.
Maintaining awareness and complying with Michigan Tailored plan authorization timeliness standards.
Participating in the “integrated health model” by looking at the member holistically and linking to appropriate programs.