Long Term Services & Support Reviewer Utilization Management - AmeriHealth Caritas : Job Details

Open to RN: Diploma, Associates, or Bachelors degree

Role Overview

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/social services licensure experience, the Reviewer reviews the 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.

Work Arrangement

• Remote

• Eastern and Central time zones preferred

Responsibilities

• Receives requests for authorization of Long Term Services and Supports available and as defined in the Community HealthChoices Program. Can include Personal Assistance Services (PAS), home care (skilled) services, Adult Day services, home-delivered meals, Durable Medical Equipment, and Environmental Modifications

• Accessing and applying Medical Guidelines for decision-making before Medical Director/Physician Advisor referral

• Applies submitted information to the Plan Community HealthChoices (CHC) authorization process (utilizing medical guidelines, Process Standards, Policies and Procedures and Standard Operating Procedures)

• Coordinates with the referral source if insufficient information is unavailable to complete the authorization process. Advises the referral source 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 when 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 enterprise platform systems in real-time (as events occur). Completes the detail line as indicated

• Provide 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, Concurrent Review)

• Submits appropriate documentation/clinical information in enterprise platform systems, record keeping, and documentation requirements

• Recognizes opportunities for referrals to the Service Coordination team and refers accordingly

Education/Experience:

• RN diploma, Associates or Bachelors degree preferred

• 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

Licensure

• Registered Nurse preferred

Skills & Abilities

• Utilize technology and resources (Excel, systems, telephones, etc.) to support work activities appropriately.

Our Comprehensive Benefits Package

Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, holidays, volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k) tuition reimbursement, and more.

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.

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Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.