AmeriHealth Caritas Long Term Services and Supports Reviewer Utilization Management in Philadelphia, Pennsylvania
Long Term Services and Supports Reviewer Utilization Management
Location: Philadelphia, PA
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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 .
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 clinical knowledge and nursing experience, the nurse 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 nurse’s discretion to pend requests for additional information and/or request clarification. The nurse 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 nurse 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 nurse 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.
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.
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 Guidelines for decision making prior to Medical Director/Physician Advisor referral.
Applies submitted information to Keystone First Community HealthChoices (KFCHC) 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 KFCHC process for requesting additional information.
Refers cases to KFHP Medical Director for medical necessity review when medical information provided does not support the nurse review process for giving an approval of services requested.
Documents case activities for Utilization determinations and discharge planning in JIVA/FEi 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 JIVA/FEi 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 KFCHC authorization timeliness standards based on DPW/NCQA requirements.
Registered Nurse ..Registered Nurse graduated from an accredited program.
Current unrestricted PA Registered Nurse license.
Valid Driver’s License and reliable automobile transportation for on-site assignments and off-site work related activities.
3 or more years’ experience in a related clinical or social services setting.
EOE Minorities/Females/Protected Veterans/Disabled