[Hiring] Long Term Services & Support Reviewer Clinical @Amerihealth Caritas

Role Description

Under the direction of the Long Term Services and Supports (LTSS) Supervisor, the UM LTSS Clinical Reviewer is responsible for completing care and service needs reviews. Using evidence-based LTSS needs assessment knowledge and clinical/social services experience, the UM LTSS Clinical Reviewer reviews the Service Coordinator and Participant requests for outpatient services, working closely with Service Coordinators to collect all information necessary to perform a thorough needs review. The UM LTSS Clinical Reviewer will:

• Send requests for additional information and/or request clarification.
• Use professional and clinical judgment to evaluate requests to ensure appropriate services are approved.
• Recognize care and service coordination opportunities and refer cases as needed.
• Apply professional and clinical judgment, clinical policies, and medical management guidelines to authorize services and deny services when guidelines are not met.
• Maintain current license, knowledge, and understanding of relevant laws, regulations, and policies.
• Understand the member’s ongoing medical conditions and triage members' needs to appropriate specialty programs.
• Work with HCBS services coordinator to ensure the plan of care reflects medical needs.

Responsibilities

• Receive requests for authorization of Long Term Services and Supports as defined in the Michigan Tailored benefit plan.
• Document the date that the request was received, nature of the request, and utilization determination.
• Verify and document Participant eligibility for services.
• Communicate and interact in real-time with providers and others to facilitate the Utilization Management process.
• Utilize technology and resources to support work activities.
• Access and apply Medical Necessity Guidelines for decision-making.
• Apply submitted information to the Michigan Tailored Plan authorization process.
• Coordinate with the referral source if insufficient information is available to complete the authorization process.
• Document case activities for Utilization determinations and discharge planning in real-time.
• Provide verbal denial notification to the requesting Service Coordinator and Participant as per policy.
• Adhere to Process Standards, Standard Operating Procedures, and Policies and Procedures.
• Submit appropriate documentation/clinical information in enterprise platform systems.
• Recognize opportunities for referrals back to the Service Coordination team.
• Participate in Quality Reviews and Inter Rater Reliability processes.
• Maintain awareness and comply with Michigan Tailored plan authorization timeliness standards.
• Participate in the “integrated health model” by linking members to appropriate programs.

Work Arrangement

• Remote role
• Seeking candidates in Michigan
• Monday - Friday 7:30 AM - 4 PM CST (8:30 AM - 5 PM EST)

Qualifications

• Bachelor's degree required.
• Registered nurse required.
• UM experience required.
• 3 or more years experience in a related clinical or social services setting.
• Expertise in addressing the needs of the Long Term Services and Support population preferred.

Benefits

• Flexible work solutions including remote options and hybrid work schedules.
• Competitive pay.
• Paid time off including holidays and volunteer events.
• Health insurance coverage for you and your dependents on Day 1.
• 401(k).
• Tuition reimbursement and more.