Long Term Services & Support Reviewer Utilization Management - RN

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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 the 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 at the Reviewer’s discretion to request additional information and clarification. The Reviewer will use their professional judgment to evaluate the request to ensure that appropriate services are approved, 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 unmet. The Reviewer will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit’s business and use 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 Services (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 the request, utilization determination (and events leading up to the determination). Verifies and documents Participant eligibility for services. Communicates and interacts in real time via “live” encounters with providers and appropriate others to facilitate and coordinate the Utilization Management process(es) activities. Utilize technology and resources (systems, telephones, etc.) to support work activities appropriately. Voice mail as an adjunct to the daily work activities versus primary reliance for giving and receiving information from Service Coordinators. Accessing and applying Medical Guidelines for decision-making before Medical Director/Physician Advisor referral. Applies submitted information to the Plan Community HealthChoices (CHC) authorization process (utilizing medical guidelines, Process Standards, Policies and Procedures, and Standard Operating Procedures). Authorizes services by medical and health benefits guidelines. Coordinates with the referral source if insufficient information is unavailable to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows the Plan CHC process for requesting additional information. Refers cases to the Plan Medical Director for medical necessity review when medical information provided does not support the nurse review process for giving approval of services requested. Documents case activities for Utilization determinations and discharge planning enterprise platform systems in real-time (as events occur). Completes the detail line as indicated. Provide verbal denial notification to the requesting Service Coordinator and Participant per policy. Generates denial letters promptly. Adheres to Process Standards, Standard Operating Procedures, and Policies and Procedures as defined by specific UM roles (Prior Authorization, Concurrent Review) Submits appropriate documentation/clinical information in enterprise platform systems, record keeping, and documentation requirements. Recognizes opportunities for referrals to the Service Coordination team and refers accordingly. Participates in quality reviews and interrater 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.