Long Term Services & Support Reviewer Utilization Management RN

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’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’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’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’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’s business and use professional judgment in their application.

Work Arrangement

• Remote role requiring residency in Eastern or Central Time Zone
• Monday through Friday, 8:30 AM to 5:00 PM EST

• Must be able to attend virtual classroom style training for a minimum of 8 weeks in its entirety

Responsibilities

• 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.
• Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination).
• Verifies and documents Participant eligibility for services.
• Communicates and interacts in a real time bases via “live” encounters with providers and appropriate others to facilitate and coordinate the activities of the Utilization Management process(es).
• 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.
• Accessing and applying Medical Necessity Guidelines for decision making.
• 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.
• 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.
• 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.
• Provides verbal denial notification to the requesting Service Coordinator and Participant as per policy. Generates denial letter in a timely manner.
• Adheres to Process Standards, Standard Operating Procedures, and Policies and Procedures, as defined by specific UM role (Prior Authorization, Concurrent Review)
• Submits appropriate documentation/clinical information in enterprise platform systems record keeping and documentation requirements.
• Recognizes opportunities for referrals back to the Service Coordination team and refers accordingly.
• Participates in Quality Reviews and Inter-Rater Reliability processes and achieves performance results at or above thresholds established by management.
• Maintains awareness and complies with Plan CHC authorization timeliness standards based on DHS/NCQA requirements

Education and Experience

• Must be a graduate of an accredited school of nursing with an active and unencumbered Registered Nurse license
• Associate Degree in Nursing required; Bachelor Degree in Nursing preferred
• 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
• Expertise and experience to include addressing needs of the Long Term Services and Support population preferred
• Utilization management experience preferably in a managed care organization desired

Licensure

• Active and unencumbered Registered Nurse (RN) license in the state of practice

Skills

• Working knowledge and experience with MS Office to include Teams, Excel, Outlook, Word, and SharePoint.
• Proficiency using electronic health record and documentation programs
• Applies clinical knowledge in order to analyse medical and functional necessity to determine whether services should be approved/denied/or reduced
• Meticulous documentation practices that adhere to regulatory and contractual standards
• Ability to meet productivity measures in an environment where tasks, decisions, and priorities may change quickly

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.