Qureos Mentor

AmeriHealth Caritas

<div>For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.
Your career starts now. We&rsquo;re looking for the next generation of health care leaders.
At AmeriHealth Caritas, we&rsquo;re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care 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. If you want to make a difference, we&rsquo;d like to hear from you.
Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 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.
Job Summary
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 experience, the Reviewer reviews 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. It is within the Reviewer&rsquo;s discretion to pend requests for additional information and/or request clarification. The Reviewer will use his/her professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care and service coordination opportunities and refer those cases as needed. The Reviewer will apply medical health benefit policy and medical management guidelines to authorize services and appropriately deny services when guidelines are not met. The Reviewer will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit&rsquo;s business and use professional judgment in their application.
Work Arrangement<ul><li>
Remote role requiring residency in Eastern or Central Time Zone</li><li>
Monday through Friday, 8:30 AM to 5:00 PM EST</li><li>
Must be able to attend virtual classroom style training for a minimum of 8 weeks in its entirety</li></ul>
Responsibilities<ul><li>
Receives requests for authorization of Long-Term Services and Supports available and as defined in the Community Health Choices Program. Authorization request examples include but are not limited to; Personal Assistance Service (PAS), home care (skilled) services, Adult Day services, Home Delivered Meals, Durable Medical Equipment and Environmental Modifications.</li><li>
Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination).</li><li>
Verifies and documents Participant eligibility for services.</li><li>
Communicates and interacts in a real time bases via &ldquo;live&rdquo; encounters with providers and appropriate others to facilitate and coordinate the activities of the Utilization Management process(es).</li><li>
Utilize technology and resources (systems, telephones, etc.) to appropriately support work activities. Voice mail as an adjunct to the daily work activities versus major reliance for giving and receiving information from Service Coordinators.</li><li>
Accessing and applying Medical Necessity Guidelines for decision making.</li><li>
Applies submitted information to Plan Community Health Choices (CHC) authorization process (utilizing medical guidelines, Process Standards, Policies and Procedures, and Standard Operating Procedures). Authorizes services in accordance with medical and health benefits guidelines.</li><li>
Coordinates with the referral source if insufficient information is not available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows Plan CHC process for requesting additional information.</li><li>
Documents case activities for Utilization determinations and discharge planning enterprise platform systems in a real time manner (as events occur). Completes detail line as indicated.</li><li>
Provides verbal denial notification to the requesting Service Coordinator and Participant as per policy. Generates denial letter in a timely manner.</li><li>
Adheres to Process Standards, Standard Operating Procedures, and Policies and Procedures, as defined by specific UM role (Prior Authorization, Concurrent Review)</li><li>
Submits appropriate documentation/clinical information in enterprise platform systems record keeping and documentation requirements.</li><li>
Recognizes opportunities for referrals back to the Service Coordination team and refers accordingly.</li><li>
Participates in Quality Reviews and Inter-Rater Reliability processes and achieves performance results at or above thresholds established by management.</li><li>
Maintains awareness and complies with Plan CHC authorization timeliness standards based on DHS/NCQA requirements</li></ul>
Education and Experience<ul><li>
Must be a graduate of an accredited school of nursing with an active and unencumbered Registered Nurse license</li><li>
Associate Degree in Nursing required; Bachelor Degree in Nursing preferred</li><li>
Minimum of 3 years of independent clinical practice experience as a Registered Nurse in outpatient ambulatory clinic, home healthcare, case management or care coordination, skilled nursing facility, long term acute care or medical-surgical required</li><li>
Expertise and experience to include addressing needs of the Long Term Services and Support population preferred</li><li>
Utilization management experience preferably in a managed care organization desired</li></ul>
Licensure<ul><li>
Active and unencumbered Registered Nurse (RN) license in the state of practice</li></ul>
Skills<ul><li>
Working knowledge and experience with MS Office to include Teams, Excel, Outlook, Word, and SharePoint.</li><li>
Proficiency using electronic health record and documentation programs</li><li>
Applies clinical knowledge in order to analyse medical and functional necessity to determine whether services should be approved/denied/or reduced</li><li>
Meticulous documentation practices that adhere to regulatory and contractual standards</li><li>
Ability to meet productivity measures in an environment where tasks, decisions, and priorities may change quickly</li></ul>
Our Comprehensive Benefits Package
Flexible work solutions including remote options, 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.</div>

Long Term Services & Support Reviewer Utilization Management RN

<div>The LTSS Director of Provider Network Management is accountable for leading the development and management of our long-term services and supports (LTSS) and home and community-based services (HCBS) networks for our Pennsylvania Community HealthChoices (CHC) managed long-term services and supports (MLTSS) Medicaid plan provider network. The CHC program serves adults aged 21 and older who are eligible for Medicaid and need LTSS services at a nursing facility level of care (either in the home with HCBS services or in a facility), including both Medicaid‑only and dual‑eligible (Medicare and Medicaid) individuals.
Reporting to the CHC VP of Plan Operations, this role ensures that the CHC KF/ACPA LTSS network development and governance infrastructure functions effectively and efficiently. This role supports the CHC market in developing and executing its LTSS network strategy at the local level and collaborates with shared service/functional partners to lead market-specific strategic initiatives that align with contractual/regulatory requirements, business priorities, and stakeholder needs. This position interacts with LTSS and HCBS provider Chief Executive Officers, Chief Financial Officers, Directors of Managed Care, and other high-level executives.
Work Arrangement: Remote with required travel to Harrisburg, PA and Ellis Preserve offices on a regular basis. Must be able to accommodate working during Eastern Time Zone. 
Responsibilities:<ul><li>
Network Strategy and Oversight:<ul><li>
Accountable for the development and execution of strategic planning for LTSS and HCBS network development and management.</li><li>
Lead the development and execution of the LTSS/HCBS network strategy to ensure sufficient provider capacity, participant access, geographic coverage, service availability, and compliance with CHC program requirements.</li><li>
Oversee network planning for core LTSS/HCBS service categories, including but not limited to personal assistance services, home health, adult day services, residential habilitation, service coordination-related provider interfaces, participant-directed services, durable medical equipment, home modifications, emergency response systems, transportation-related supports, and other community-based services.</li></ul></li><li> 
Provider Contracting and Negotiations:<ul><li>
Oversee LTSS/HCBS provider contracting strategy, including contract development, rate negotiations, contract amendments, provider terminations, new provider onboarding, and value-based payments (VBP).</li><li>
Ensure provider contracts align with state Medicaid requirements, health plan policies, value-based care priorities, quality expectations, claims requirements, credentialing standards, and operational performance expectations.</li><li>
Lead or support negotiations with high-impact providers, including large home care agencies, adult day, residential providers, specialized LTSS providers, and regional provider organizations, among others.</li></ul></li> 
<li>
Regulatory and Compliance Alignment<ul><li>
Ensure providers receive timely guidance regarding contractual requirements, claims processes, authorization protocols, Electronic Visit Verification (EVV) expectations, quality initiatives, and regulatory changes.</li><li>
Ensure the LTSS/HCBS provider network meets all applicable state, contractual, and internal network adequacy standards.</li><li>
Lead ongoing monitoring of access indicators, including provider availability, service initiation timeliness, geographic coverage, specialty service gaps, participant complaints, grievance trends, authorization delays, and service interruption risks.</li></ul></li></ul><ul><li> 
Provider Engagement, Relationship Management, and Performance Management: 
<ul><li>
Build and maintain effective relationships with LTSS/HCBS providers, provider associations, community organizations, advocacy groups, and state partners.</li><li>
Lead provider engagement strategies that promote transparency, responsiveness, operational clarity, and shared accountability for participant outcomes.</li><li>
Oversee LTSS/HCBS provider forums, trainings, communications, issue-resolution processes, and escalation pathways</li></ul></li> 
<li>
Team Leadership and Talent Development:<ul><li>
Foster team engagement and growth through consistent coaching, mentorship, and performance evaluations, supporting career development while addressing performance gaps in a timely and effective manner.</li><li>
Responsible for departmental staffing decisions and providing supervision to assigned staff, writes and performs annual reviews, and monitors performance issues as they arise.</li><li>
Establish clear goals, accountability structures, workflows, and performance expectations for direct reports and functional teams. 
Foster a culture of collaboration, regulatory discipline, provider partnership, operational excellence, and continuous improvement.</li></ul></li></ul> 
Education/Experience:<ul><li>
Bachelor&rsquo;s degree (or equivalent experience) in Business or health related disciplines such as Healthcare Administration or Healthcare management or equivalent business experience.</li><li>
8 to 10 years of progressive business management.</li><li>
5 to 10 years Managed Care industry experience including contracting and reimbursement experience.</li><li>
5 or more years people management experience, managing teams and project management.</li><li>
3 years Medicaid and long term services and support (LTSS) and home and community based service (HCBS) experience required; new program implementation experience preferred; knowledge base of Medicare crossover claims set up and oversight required.</li><li>
A valid driver&rsquo;s license and current auto insurance required.</li></ul> 
Our Comprehensive Benefits Package
Flexible work solutions including remote options, 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. 
For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.
Your career starts now. We&rsquo;re looking for the next generation of health care leaders.
At AmeriHealth Caritas, we&rsquo;re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care 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. If you want to make a difference, we&rsquo;d like to hear from you.
Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 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.</div>

Director Provider Network Management Long Term Services & Support

<div>Role Overview: The Care Manager II is responsible for managing and coordinating care, services, and social determinants of health for medically fragile members with acute, chronic, medically complex, and/or behavioral health conditions, as well as other health needs. Serves as the primary point of contact for the care team, including members, caregivers, physicians, and community support, to guide members toward their optimal level of health. Utilizes strong assessment and communication skills, critical thinking, and clinical knowledge to identify issues, gaps in care, and barriers to care. Develops a plan of care through shared decision-making with the member/caregiver and in collaboration with providers and other care team members to improve the member&rsquo;s health status and compliance with treatment plans, as well as promote self-management.
Work Arrangement:<ul><li>
Remote - Associate must reside in the state of Michigan (MI)</li></ul>
Responsibilities:<ul><li>
Support members during transitions of care through assessment, coordination of care, education on the discharge plan of care, referrals, and evaluation of the plan's effectiveness.</li><li>
Review the medication list, educate members on pharmacy needs, and counsel on side effects and mitigation strategies for specific treatment protocols.</li><li>
Evaluate, monitor, and update the care plan through regularly scheduled follow-up contacts based on the member/caregiver's progress, needs, and preferences.</li><li>
Establishes points of contact to collaborate with identified community, medical, and/or behavioral health teams.</li><li>
Where applicable, maintain timely, complete, and accurate documentation of member interactions in the electronic care management platforms.</li><li>
Monitor appropriate utilization, coordinate services with other payer sources, make appropriate referrals, and identify and escalate quality-of-care issues.</li><li>
Develop a working knowledge of the electronic care management platforms, care management programs, policies, standard operating procedures, workflows, member insurance products and benefits, community resources and programs, and applicable regulatory, state, and National Committee for Quality Assurance (NCQA) requirements.</li><li>
May identify cases to be presented at care management rounds and follow up with providers on recommendations to achieve optimal outcomes for members.</li><li>
For education and/or assessment, face-to-face visits may be required at the member&rsquo;s residence, provider&rsquo;s office, hospitals, other acute locations, or community locations.</li></ul>
Education &amp; Experience:<ul><li>
Associate Degree in Nursing required.</li><li>
Bachelor of Science in Nursing preferred.</li><li>
Current, active, and unrestricted Registered Nurse (RN) licensure in MI.</li><li>
3 or more years of experience at the bedside working with high acuity behavioral health needs and/or medically frail patients in an acute care, home care, or special needs clinic</li><li>
3 or more years of case management experience, preferably by telephone, within a managed care organization, is desired.</li><li>
Demonstrated proficiency working within Office 365, including MS Office (Excel, Word, Outlook) and electronic medical record and documentation programs.</li></ul>
Licensure:<ul><li>
Current, active, and unrestricted Registered Nurse licensure in MI.</li><li>
Eligible to sit for the Case Management certification after 12 months of employment. Must obtain this certification within 24 months of employment.</li><li>
Valid driver's license and car insurance.</li><li>
Must be willing to drive a personal vehicle for work-related events/meetings.</li></ul>
Skills &amp; Abilities:<ul><li>
Support a positive workplace environment, collaborate, and share clinical knowledge and skills to support our culturally and demographically diverse member population.</li></ul></div>

Care Manager II

<div>For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.
Your career starts now. We are looking for the next generation of health care leaders.
At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nations leaders in health care 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. If you want to make a difference, we would like to hear you.
Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 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.
Role Overview:
The Investigator is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving the full range of products at the AmeriHealth Caritas Family of Companies (ACFC).
Work Arrangement:<ul><li>
Remote within the United States, preferably in South Carolina</li></ul> 
Responsibilities:<ul><li>
Ensures compliance with all requirements related to Special Investigation Units and fraud, waste and abuse investigations.</li><li>
Conducts investigations of potential fraud, waste and/or abuse with a focus on thoroughness and attention to detail, quality, timeliness and cost control.</li><li>
Conducts comprehensive interviews with providers, members and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence.</li><li>
Proactively performs research using the Internet, data analysis tools, etc., to analyze aberrant claims billing and practice patterns.</li><li>
Analyzes data as part of the investigative process using available fraud detection software and corporate resources.</li><li>
Represents ACFC in conducting settlement negotiations with providers, counsel and/or other associated parties.</li><li>
Prepares and submits investigative reports covering all phases of the investigation.</li><li>
Interprets and conveys highly technical information to others.</li><li>
Establishes and maintains liaison with public officials, law enforcement and others to obtain assistance in conducting investigations.</li>
Performs necessary functions to support all aspects of SIU investigations and responsibilities to include, but not limited to: Intake; Screening; Reviews; Referrals; Recoveries; and Provider Investigative Site Visits. 
<li>
</li></ul> 
Education/ Experience:<ul><li>
Bachelor's degree with a minimum of two years of experience in the healthcare field working in fraud, waste, and abuse investigations and audits OR</li><li>
An associate's degree, with a minimum of four years of experience working in healthcare fraud, waste, and abuse investigations and audits.</li><li>
High School Diploma or GED required.</li><li>
Experience and training/certifications commensurate with position requirements in lieu of formal educational requirements for the SIU Investigator position may be considered.</li><li>
Valid driver&rsquo;s license required</li><li>
Experience with Data Analytics preferred.</li><li>
Ability to work independently with minimal supervision, and manage a high volume of assignments.</li><li>
Strong verbal and written communication skills.</li><li>
High degree of integrity and confidentiality required handling information that is considered personal and confidential.
</li><li>Analytical skills and ability to make deductions; logical and sequential thinker.</li><li>
3+ years experience conducting comprehensive health care fraud investigations; interacting with state, federal and local law enforcement agencies strongly preferred.</li></ul> 
Other Skills:<ul><li>
Health care industry and/or Medicare/Medicaid required</li><li>
Pharmacy/Behavioral Health/Pharmacy Benefit Management knowledge strongly preferred</li><li>
Clinical and pharmacy experience preferred</li><li>
SIU and/or State Medicaid regulatory compliance work experience preferred.</li><li>
Knowledge and proficiency in claims adjudication standards &amp; procedures preferred.</li><li>
Solid knowledge of Medicaid, Medicare, and pharmacy benefit laws and requirements; federal, state, civil and criminal statutes.</li><li>
Experience with decision support tools used for data analysis.</li><li>
Advanced knowledge and experience working on various approaches to fraud, waste and abuse.</li><li>
Working knowledge of Microsoft applications, especially Excel required.</li><li>
Knowledge of available resources (internal and external) to assist in investigations.</li></ul> 
Our Comprehensive Benefits Package
Flexible work solutions including remote options, 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.</div>

Special Investigator

<div>For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.
Role Overview
The Manager Application Development will lead a cross-functional team supporting the CYBER platform, New Jersey&rsquo;s Children&rsquo;s Behavioral Health system, which serves as a statewide system for care coordination, utilization management, and outcomes tracking. This role drives delivery, stability, and compliance of a mission-critical healthcare platform.
Work Arrangement<ul><li>
The is a hybrid, office based position located at our Robbinsville, NJ office. Core office days are Tuesday, Wednesday, and Thursday.</li></ul>
Responsibilities<ul><li>
Team Leadership: Manage and mentor a team of 13&ndash;14 Developers (.Net &amp; Angular, QA, SQL)</li><li>
Delivery Ownership: Drive end-to-end Agile SDLC delivery (build, test, release)</li><li>
Platform Management: Oversee enhancements and support of the CYBER EHR platform</li><li>
Stakeholder Engagement: Partner with business, state, and IT leadership teams</li><li>
Quality &amp; Performance: Ensure high-quality releases, system reliability, and scalability</li><li>
Compliance: Maintain adherence to HIPAA and NJ state regulatory requirements</li><li>
Reporting: Provide concise updates on delivery status, risks, and outcomes</li><li>
Experience modernizing legacy systems</li></ul> 
Education and Experience<ul><li>
At least ten (10)+ years of applications development experience</li><li>
At least five (5)+ years of experience managing development teams</li><li>
Experience in healthcare/EHR or regulated environments</li><li>
Strong experience in Full stack development (.NET, Angular or similar)</li><li>
Strong experience SQL/database development</li><li>
Strong experience in QA/testing practices</li><li>
Experience with Agile (Scrum/Kanban) and DevOps</li></ul> 
Other Skills<ul><li>
Previous Behavioral Health or Medicaid system experience</li><li>
Familiarity with NJ state healthcare systems</li><li>
Experience with Azure, APIs, and enterprise integrations</li><li>
Experience with JIRA / Azure DevOps</li><li>
Ability to deliver on-time, high-quality releases</li><li>
Strong team performance and engagement experience</li><li>
Ability to build and maintain a stable and scalable CYBER platform</li><li>
High stakeholder satisfaction</li></ul> 
Our Comprehensive Benefits Package
Flexible work solutions including remote options, 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.
Your career starts now. We are looking for the next generation of health care 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 health care 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. If you want to make a difference, we would like to connect with you.
Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 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.</div>

Manager Applications Development, CYBER Platform

<div>For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.
Your career starts now. We&rsquo;re looking for the next generation of health care leaders.
At AmeriHealth Caritas, we&rsquo;re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care 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. If you want to make a difference, we&rsquo;d like to hear from you.
Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 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.
The Care Connector is responsible for supporting the daily operations of integrated care management and utilization management program interventions. The Care Connector performs in a contact center environment, effectively processing calls from Members, Providers, and other areas, internal and external to the company. Under the direction of Clinical staff, the Care Connector will provide members with educational materials and carry out strategies to increase healthcare adherence and reduce barriers to care.
Education/Experience:<ul><li>
High School Diploma or equivalent required</li><li>
Minimum of two (2) years of work experience in a healthcare environment required</li><li>
Minimum of one (1) year of telephonic customer service experience required, preferably within a healthcare setting</li><li>
Managed care experience preferred</li><li>
Medical terminology, ICD, CPT, and/or coding experience preferred</li><li>
Strongly prefer Medical Assistant, Home Health Aide, Nursing Assistant, or other similar health care para-professional training or certification</li><li>
Prior member service or customer service telephone experience desired</li><li>
Prior behavioral health experience is a plus</li><li>
Excellent interpersonal and verbal communication skills and the ability to write clear and concise reports</li><li>
Attention to detail and confidentiality with strong organizational skills</li></ul>
Skills &amp; Abilities:<ul><li>
Proficient PC skills in a Windows-based environment, MS Office products, including word processing, spreadsheets, and database programs</li></ul>
Our Comprehensive Benefits Package
Flexible work solutions including remote options, 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.</div>

Care Connector

<div>For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.
Your career starts now. We are looking for the next generation of health care 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 health care 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. If you want to make a difference, we would like to connect with you.
Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 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.
Responsibilities:
The Clinical Case Manager assists members who are eligible for LTSS in obtaining the services they need as required by DSHP Plus LTSS in New Castle county. He or she contributes to the LTSS case management process by performing telephonic and/or face-to-face assessments for the identification, evaluation, coordination and management of member&rsquo;s needs, including physical health, behavioral health, social services and long term services and supports. This position is also responsible for completing Level of Care Redeterminations for home and community based members annually. This requires clinical review when evaluating the need for a member to remain in the program. The Clinical Case Manager will also provide clinical support to his/her non-licensed counterparts and may act as a secondary case manager when a member is experiencing an acute episode.<ul><li>
Coordination of care for medically complex LTSS Members receiving private duty nursing (PDN)</li><li>
Performs follow-up on outstanding items of need and maintains a calendar or PDN Coverage.</li><li>
Establish communication method to effectively communicate with multiplePDN agencies and member/member representative.</li><li>
Coordinates and collaborates with prior authorization team to make sure all necessary precertifications for required services are submitted for review. Assists in obtaining the Letter of Medical Necessity (LOMN) as needed</li><li>
Coordinate with provider network team in the utilization of non-contracted providers or facilities as necessary following the single case agreement (SCA) process</li><li>
Conducts reevaluation of level of care annually or more frequently as needed in accordance with DSHP Plan Plus LTSS requirements.</li><li>
Provides clinical support to non-licensed case managers as needed.</li><li>
Conduct condition specific assessments with members with chronic conditions. Provide education and routine follow-up with member.</li><li>
Perform initial clinical assessment of new members, develop care plan, and initiate services.</li><li>
Facilitate person-centered planning team meetings to coordinate care and services. Identify, coordinate, and assist participants in gaining access to needed LTSS and other Covered Services, as well as non-covered medical, social, housing, educational, and other services and supports.</li><li>
Provides information to participants and conducts monitoring of authorized services and supports for Participants.</li><li>
Informs participants about available LTSS required needs assessments, the care plan process, service alternatives and service delivery options.</li><li>
Informs participants of their rights and responsibilities as well as assists with the complaint, grievance, and DHS Fair Hearing process.</li><li>
Collects additional necessary information, including participant preferences, strengths, and goals to inform the development of the Plan of Care.</li><li>
Conducts comprehensive needs assessments annually or more frequently as needed in accordance with requirements.</li><li>
Review and acting upon worklists in Jiva, including monitoring of new members</li><li>
Authorize urgent services when needed</li><li>
Monitoring critical incident reporting/documentation, recommending/taking action w/ other corporate entities as required</li><li>
Liaison activities with Physical health Care Coordination program</li><li>
Working with LTSS and DSNP members to complete comprehensive assessments, care plans, medication reconciliation, monitoring follow-up and progress, and assisting with discharge planning/transitions of care.</li></ul>
Education/Experience:<ul><li>
Delaware licensed RN required.</li><li>
Ability to travel throughout entire state of DE.</li><li>
Valid driver&rsquo;s license required</li><li>
Knowledge of the home and community-based service system and how to access and arrange for services</li><li>
Experience conducting LTSS needs assessments and monitoring LTSS delivery</li><li>
Ability to provide informed advocacy</li><li>
Ability to interact with members face to face</li><li>
Ability to interact with health care professionals in a professional manner</li><li>
Ability to travel up to 75%</li><li>
Duties may include case management responsibilities based on business needs. This role is also a part of the contingency plan, where a caseload may be assigned in the event of a staffing need</li></ul>
Our Comprehensive Benefits Package
Flexible work solutions including remote options, 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.</div>

Clinical Case Manager DE Long Term Services & Support-Private Duty Nursing

Join AmeriHealth Caritas and explore 9   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.