Long Term Services & Support Reviewer Utilization Management - RN

Amerihealth Caritas•,

7d•Hybrid

About The Position

Your career starts now. We are looking for the next generation of healthcare leaders. At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare 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. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. We want to connect with you if you're going to make a difference. Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with over 30 years of experience. We deliver 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. Discover more about us at www.amerihealthcaritas.com.

Requirements

Three or more years of experience in a related clinical or social services setting
Expertise and experience in addressing the needs of the Long Term Services and Support population.

Nice To Haves

Bachelor’s Degree
Professional licensure in health care or social services-related field
Registered Nurse

Responsibilities

Completing care and service needs reviews.
Reviewing Service Coordinator and Participant requests for inpatient and outpatient services, working closely with Service Coordinators to collect all information necessary to perform a thorough needs review.
Requesting additional information and clarification as needed.
Evaluating requests to ensure appropriate services are approved, recognizing care and service coordination opportunities, and referring those cases as needed.
Applying medical health benefit policy and medical management guidelines to authorize services and appropriately identifying and referring requests to the Medical Director when guidelines are unmet.
Maintaining current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit’s business and using clinical judgment in their application.
Receiving requests for authorization of Long Term Services and Supports available and as defined in the Community HealthChoices Program (e.g., Personal Assistance Services (PAS), home care (skilled) services, Adult Day services, home-delivered meals, Durable Medical Equipment, and Environmental Modifications).
Documenting date that the request was received, nature of the request, utilization determination (and events leading up to the determination).
Verifying and documenting Participant eligibility for services.
Communicating and interacting in real time via “live” encounters with providers and appropriate others to facilitate and coordinate the Utilization Management process(es) activities.
Utilizing technology and resources (systems, telephones, etc.) to support work activities appropriately.
Accessing and applying Medical Guidelines for decision-making before Medical Director/Physician Advisor referral.
Applying submitted information to the Plan Community HealthChoices (CHC) authorization process (utilizing medical guidelines, Process Standards, Policies and Procedures, and Standard Operating Procedures).
Authorizing services by medical and health benefits guidelines.
Coordinating with the referral source if insufficient information is unavailable to complete the authorization process.
Advising the referral source and requesting specific information necessary to complete the process.
Referring cases to the Plan Medical Director for medical necessity review when medical information provided does not support the nurse review process for giving approval of services requested.
Documenting case activities for Utilization determinations and discharge planning enterprise platform systems in real-time (as events occur).
Providing verbal denial notification to the requesting Service Coordinator and Participant per policy.
Generating denial letters promptly.
Adhering to Process Standards, Standard Operating Procedures, and Policies and Procedures as defined by specific UM roles (Prior Authorization, Concurrent Review).
Submitting appropriate documentation/clinical information in enterprise platform systems, record keeping, and documentation requirements.
Recognizing opportunities for referrals to the Service Coordination team and referring accordingly.
Participating in quality reviews and interrater reliability processes and achieving performance results at or above thresholds established by management.
Maintaining awareness and complying with Plan CHC authorization timeliness standards based on DHS/NCQA requirements.