Long Term Services & Support Reviewer Utilization Management

Company: Amerihealth
Location: Harrisburg
Posted on: March 20, 2023

Job Description:

Job Description:

\n\n\n\n Your career starts now. We're looking for the next generation of health care leaders.\n 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.\n Headquartered in Philadelphia, 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.\n\n\n\n\n\n\n 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 uses professional judgment in their application. \n Responsibilities: \n 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.\n\nDocuments date that the request was received, nature of request, utilization determination (and events leading up to the determination).\nVerifies and documents Participant eligibility for services.\nCommunicates 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).\nUtilize 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.\nAccessing and applying Medical Necessity Guidelines for decision making.\nApplies 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.\nCoordinates 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.\nDocuments case activities for Utilization determinations and discharge planning enterprise platform systems in a real time manner (as events occur). Completes detail line as indicated.\nProvides verbal denial notification to the requesting Service Coordinator and Participant as per policy. Generates denial letter in a timely manner.\nAdheres to Process Standards, Standard Operating Procedures, and Policies and Procedures, as defined by specific UM role (Prior Authorization, Concurrent Review)\nSubmits appropriate documentation/clinical information in enterprise platform systems record keeping and documentation requirements.\nRecognizes opportunities for referrals back to the Service Coordination team and refers accordingly.\nParticipates in Quality Reviews and Inter Rater Reliability processes and achieves performance results at or above thresholds established by management.\nMaintains awareness and complies with Plan CHC authorization timeliness standards based on DHS/NCQA requirements. \n\n\n Education/ Experience:\n\nBachelor's Degree.\n3 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 preferred.\n \n\n\nBack\n\n\n\n\n\n\n\n\nApply Now\n\n

Keywords: Amerihealth, Harrisburg , Long Term Services & Support Reviewer Utilization Management, Executive , Harrisburg, Pennsylvania