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 Lead Reviewer is responsible for assisting the Supervisor in the daily operations of the department, including but not limited to, training and mentoring new and existing associates. The Lead 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.

Responsibilities:

• Serves as a subject matter expert for LTSS training for internal care teams and external audiences.
• Plans, develops and supports or conducts orientations, training programs and creates educational material for staff members to improve skills, aid in professional growth and development and to ensure staff’s expertise
• Reviews quality audits and provides necessary education to improve performance.
• 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.
• 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 Necessity Guidelines for decision making.
• Applies 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.
• 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 Plan CHC process for requesting additional information.
• Documents case activities for Utilization determinations and discharge planning enterprise platform systems 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 enterprise platform systems 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 Plan CHC authorization timeliness standards based on DHS/NCQA requirements.

Education/ Experience:

• Bachelor’s Degree.
• 3 or more years’ experience as an LTSS UM Reviewer.