LTC Utilization Management Reviewer

Presbyterian Healthcare Services

11d • Onsite

About The Position

Build your Career. Make a Difference. Presbyterian is hiring a skilled LTC Utilization Management Reviewer to join our team. Now Hiring: LTC Utilization Management Reviewer Summary: Build your Career. Make a Difference. Presbyterian is hiring a skilled LTC Utilization Management Reviewer to join our team.

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; or 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

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

Responsibilities

• Responsible for conducting Nursing (NF) Facility Level of Care (LOC) determinations according to state regulations and criteria.
• Performs 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.
• Utilizes LTSS skills and established criteria to review, coordinate, document and approve all aspects of the utilization/benefit management program, including but not limited to community benefit care plans and self-directed community benefit care plans and budgets.
• Validates and interprets documentation using approved LTSS criteria.
• Consults with PHP medical directors and refers 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.
• Refers cases for Quality Management review and Special Investigative Review as indicated for quality of care issues and possible abuse/fraud
• NF LOC evaluations and determinations, Responsible for the review of all required medical documentation against HSD criteria and to provide an objective evaluation and determination of NF LOC medical eligibility (approvals and denials).
• Documents 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.
• Refers all NF LOC denials to the health plans medical director for review.
• Prepares files and participates in state fair hearing procedures.
• Reviews agency-based community benefit care plans for appropriateness according to established LTC benefit UM criteria and guidelines and according to required timelines.
• Approves (full or partial) or denies care plan according to criteria and available documentation Documents Agency-based community benefit care plan approvals, partial approvals and denials in PHPs case management system according to policies and procedures and job-aids.
• Reviews self-directed community benefit care plans and budgets for appropriateness according to established LTC benefit UM criteria and guidelines and according to required timelines.
• Approves (full or partial) or denies care plan according to criteria and available documentation Reviews 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.
• Documents self-directed community benefit care plan and budget approvals, partial approvals and denials in PHPs case management system and the Fiscal Management agencys information system according to policies and procedures and job-aids.

Benefits

• All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.
• Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

What This Job Offers

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