LTSS Utilization Management Nurse

US-CA-Irvine
Req No.
2017-2228
Category
Operations
Type
Regular Full-Time

Overview

ConcertoHealth delivers comprehensive care to Medicare, Medicaid, and complex-needs patients. For over a decade, we have provided extraordinary outcomes for thousands of people in these underserved groups.

 

The ConcertoHealth name reflects our unique approach to healthcare. It’s about how we work in concert with patients, providers, and health plans. It’s about the harmony of a patient’s care, health, and dignity.

This position is responsible for promoting the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to review of LTSS.

 

Responsibilities

  • Responsible for reviewing recommendations for Home and Community Based Waiver services as well as Personal Care Services. Responsible for reviewing documentation related to the requested services to evaluate if the service is appropriate for the individual and documentation supports the need for service.

 

  • Ensures that reviews are completed in a timely fashion to meet contractual requirements and are conducted using established guidelines including state regulations, contractual requirements and Concerto Policy.

 

  • As needed, reach out to the requesting care manager or care management supervisor if documentation does not support the service to request additional supporting documentation.

 

  • Utilizes designated criteria and guidelines along with clinical knowledge to evaluate the appropriateness of services.

 

  • Applies appropriate benefits information to determine if requested services are a covered benefit under the member’s Health Plan.

 

  • Applies clinical knowledge and experience to process requests for services and supplies.

 

  • Identifies potential quality of care issues and refers to the Quality Department.

 

  • Meets service standards for turn-around times for decisions.

 

Qualifications

Education: Bachelor’s Degree required.

Experience: Minimum of two years of experience in assessing individuals for Home and Community Based Waiver Services and Personal Care Services. Experience in evaluating clinical records and documentation related to LTSS. Four (4) years’ utilization management experience preferred.  Must possess a strong understanding of Managed Care principles. License / Certification: Requires a valid, unrestricted state nursing license (RN or LVN), or Social Work license. Computer Skills: Basic computer skills in a Windows operating environment including Microsoft Word, Excel, and an e-mail system.  Knowledge / Skills / Abilities: High energy; demonstrates an ability to function in a creative, entrepreneurial environment and “think outside the box.”

 

Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization management.

 

Knowledge of healthcare delivery and management.

 

Able to demonstrate strong knowledge of the authorization review process and workflow.

 

Intermediate computer literacy (MS Office) and typing skills are necessary.

 

Strong interpersonal and decision-making skills; must be able to introduce new ideas, processes, and tools to improve department performance.

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