LTC Utilization Management Reviewer

Presbyterian Healthcare Services

3d • Onsite

About The Position

Presbyterian is hiring a skilled LTC Utilization Management Reviewer to join our team. This full-time, exempt position is based at the Reverend Hugh Cooper Administrative Center and operates on a day shift. The role is responsible for conducting Nursing (NF) Facility Level of Care (LOC) determinations according to state regulations and criteria. It involves performing utilization review activities to ensure that services rendered to members meet Long Term Care Supports and Services (LTSS) criteria and services are delivered in the appropriate setting. The reviewer will utilize LTSS skills and established criteria to review, coordinate, document, and approve all aspects of the utilization/benefit management program, including community benefit care plans and self-directed community benefit care plans and budgets. This includes validating and interpreting documentation using approved LTSS criteria, consulting with PHP medical directors, and referring cases for medical director decisions on complex cases. Additionally, the role involves referring cases for Quality Management review and Special Investigative Review as indicated for quality of care issues and possible abuse/fraud.

Requirements

• Active Nursing license in NM or compact license (RN or LPN) with a minimum of one year of relevant experience
• Medical Social Worker with a minimum of one year of relevant experience
• Physical, Occupational, or Rehab Therapists with a minimum of one year of relevant experience.
• Knowledge of all state and federal regulations concerning the use, disclosure, and confidentiality of all patient records.
• Analytical skills as applicable to interpret provider communication and medical records.
• Attention to detail and organizational skills.
• Ability to articulate orally and in writing an understanding of complex issues and detailed action plans, while best representing the organization professionally.
• Ability to work cooperatively with other employees and departments.
• Efficient and comfortable with computer electronic data entry and documentation.
• Ability to succinctly document using correct spelling and grammar.
• Able to summarize from medical clinical notes, progress notes, needs assessments, functional assessments, progress notes, history and physicals, care plans and other state required documentation.
• Able to meet timelines and deadlines associated with work load.

Nice To Haves

• 1 year of experience in MCO, health plan insurance environment, with expertise performing utilization management or experience working in long term care services

Responsibilities

• Conducting Nursing (NF) Facility Level of Care (LOC) determinations according to state regulations and criteria.
• Performing utilization review activities to ensure that services rendered to members meet Long Term Care Supports and Services (LTSS) criteria and services are delivered in the appropriate setting.
• Utilizing LTSS skills and established criteria to review, coordinate, document and approve all aspects of the utilization/benefit management program, including community benefit care plans and self-directed community benefit care plans and budgets.
• Validating and interpreting documentation using approved LTSS criteria.
• Consulting with PHP medical directors and referring for medical director decisions on cases not meeting LTSS criteria, NF LOC denials and care plans that result in a reduction in service or benefit denial.
• Referring cases for Quality Management review and Special Investigative Review as indicated for quality of care issues and possible abuse/fraud.
• Performing NF LOC evaluations and determinations.
• Reviewing all required medical documentation against HSD criteria and providing an objective evaluation and determination of NF LOC medical eligibility (approvals and denials).
• Documenting recommendations and NF LOC determinations (approvals, request for more information and denials in PHPs case management system, including appropriate documentation of authorization and NF LOC begin and end date eligibility spans according to established HSD policies.
• Referring all NF LOC denials to the health plans medical director for review.
• Preparing files and participating in state fair hearing procedures.
• Reviewing agency-based community benefit care plans for appropriateness according to established LTC benefit UM criteria and guidelines and according to required timelines.
• Approving (full or partial) or denying care plans according to criteria and available documentation.
• Documenting Agency-based community benefit care plan approvals, partial approvals and denials in PHPs case management system according to policies and procedures and job-aids.
• Reviewing self-directed community benefit care plans and budgets for appropriateness according to established LTC benefit UM criteria and guidelines and according to required timelines.
• Approving (full or partial) or denying care plans according to criteria and available documentation.
• Reviewing care plans to assure the overall cost of the community benefit care plan does not exceed the overall cost of care in a nursing home based on the benchmark provided by HSD.
• Documenting self-directed community benefit care plan and budget approvals, partial approvals and denials in PHPs case management system and the Fiscal Management agency's information system according to policies and procedures and job-aids.

Benefits

• Medical
• Dental
• Vision
• Short-term disability
• Long-term disability
• Group term life insurance
• Optional voluntary benefits
• Wellness rewards program (earn gift cards and more by participating in wellness activities like wellness challenges, webinars, preventive screenings, and more)

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed