Ltss Reviewer Utilization Management - Remote

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 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 identify and refer requests to the Medical Director 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 uses clinical judgment in their application.

Responsibilities:

• Recognizes opportunities for referrals back to the Service Coordination team and refers accordingly.
• 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.
• Verifies and documents Participant eligibility for services.
• Receives requests for authorization of Long Term Services and Supports available and as defined in the Community HealthChoices 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.
• Adheres to Process Standards, Standard Operating Procedures, and Policies and Procedures, as defined by specific UM role (Prior Authorization, Concurrent Review)
• 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).
• 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.
• Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination).
• Applies submitted information to Plan Community HealthChoices (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.
• Submits appropriate documentation/clinical information in enterprise platform systems record keeping and documentation requirements.
• 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 Guidelines for decision making prior to Medical Director/Physician Advisor referral.
• 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.
• Provides verbal denial notification to the requesting Service Coordinator and Participant as per policy. Generates denial letter in a timely manner.
• Refers cases to Plan Medical Director for medical necessity review when medical information provided does not support the nurse review process for giving an approval of services requested.

Education/ Experience:

• Bachelor’s Degree
• Professional licensure in health care or social services related field
• 3 or more years’ experience in a related clinical or social services setting. Expertise and experience to include addressing needs of the Long Term Services and Support population.