AmeriHealth Caritas
Your career starts now. Weāre looking for the next generation of health care leaders. At AmeriHealth Caritas, weāre 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. We'd like to hear from you if you want to make a difference. Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with over 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.
Education/ Experience: Bachelorās Degree required. Registered Nurse required. 3 or more yearsā experience in a related clinical or social services setting required. Quality or QA experience preferred Managed care or utilization review experience preferred. Other Skills: Strong written and verbal communication skills Decision-making skills with the ability to identify problems and recommend solutions Self-directed, able to work independently.
Under the direction of the Long-Term Services and Supports (LTSS) Supervisor, the LTSS UM Correspondence RN is responsible for creating, writing, editing, and completing all LTSS UM Review adverse decision notices within required timeframes. The LTSS UM QA Letter Analyst will use regulatory and accreditation departmental standards and apply medical health benefit policy and medical management guidelines to ensure letters provide the appropriate justification for authorizing services and appropriately deny services when guidelines are unmet. The QA Analyst will maintain current knowledge and understanding of the laws, regulations, DHS/NCQA requirements, and policies that pertain to the organizational unitās business and use professional judgment in their application. ; This position will report noncompliance or other trends to leadership as appropriate.
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