Ltss Coordinator Jobs

Relevant Work Experience, Knowledge, Skills, and Abilities

Certification in utilization or care management preferred.

Experience in case management/care coordination, managed care, and/or utilization management. (P).

Assist the entire Care Management interdisciplinary team in managing members with Care Management needs.

Research evidence-based guidelines, medical protocols, provider networks, and on-line resources in making care management recommendations.

Maintain an understanding of Care Management principles, program objectives and design, implementation, management, monitoring, and reporting.

Manages members with chronic illnesses, co-morbidities, and/or disabilities, to insure cost effective and efficient utilization of health benefits.

Preferred Skills, Capabilities, and Experiences:

Interfaces with Medical Directors, Physician Advisors and/or Inter-Disciplinary Teams on the development of care management treatment plans.

May require state-specified certification based on state law and/or contract.

Job Family: Medical and Clinical

Date Posted: Aug 01, 2023

Participates in Quality Reviews and Inter Rater Reliability processes and achieves performance results at or above thresholds established by management.

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

Maintains awareness and complies with Plan CHC authorization timeliness standards based on DHS/NCQA requirements.

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.

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.

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

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.

Accesses and applies Medical Necessity Guidelines for decision making.

Adheres to Process Standards, Standard Operating Procedures, and Policies and Procedures, as defined by specific UM role (Prior Authorization, Concurrent Review)

Performs and remains knowledgeable in all workflow and timeliness requirements for all areas in Utilization Management

Strong knowledge base of health care resources, ideally with managed care experience.

Monitors staff work assignments and makes appropriate adjustments based on staffing levels, staff experience, and number/request types of authorizations/appeals received.

Assist the LTSS UM Manager in providing oversight for operational reporting compliance

Assesses candidates and ensures that optimal qualifications are met as a member of the department’s interview team.

Reviews quality audits and shares audit results in a timely manner with associates, providing necessary education and counseling to improve performance.

Demonstrated presentation and team facilitation skills

Excellent oral and written communication skills

Applying for this job indicates your acknowledgement and understanding of the following statements:

Coordinate and provide information to support quality improvement studies, initiatives and accreditation reviews.

Bachelor’s Degree in a health care or quality related field.

Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability.