LTC Utilization Management Reviewer

About the role

Build your Career. Make a Difference. Presbyterian is hiring a skilled LTC Utilization Management Reviewer to join our team. Type of Opportunity: Full time Job Exempt: Yes Job is based: Reverend Hugh Cooper Administrative Center Work Shift: Days (United States of America)

Responsibilities

• Now hiring a Utilization Management Reviewer-LTC
• Some key responsibilities include:
• NF LOC evaluations and determinations,
• Responsible for the review of all required medical documentation against HSD criteria and to provide an objective evaluation and determination of NF LOC medical eligibility (approvals and denials).
• Prepares files and participates in state fair hearing procedures.
• Reviews agency-based community benefit care plans for appropriateness according to established LTC benefit UM criteria and guidelines and according to required timelines. Approves (full or partial) or denies care plan according to criteria and available documentation
• Documents Agency-based community benefit care plan approvals, partial approvals and denials in PHPs case management system according to policies and procedures and job-aids.
• Reviews self-directed community benefit care plans and budgets for appropriateness according to established LTC benefit UM criteria and guidelines and according to required timelines. Approves (full or partial) or denies care plan according to criteria and available documentation
• Reviews care plans to assure the overall cost of the community benefit care plan does not exceed the overall cost of care in a nursing home based on the benchmark provided by HSD.
• Documents self-directed community benefit care plan and budget approvals, partial approvals and denials in PHPs case management system and the Fiscal Management agencys information system according to policies and procedures and job-aids.

Requirements

• Active Nursing license in NM or compact license (RN or LPN) with a minimum of one year of relevant experience
• Medical Social Worker with a minimum of one year of relevant experience; or
• Physical, Occupational, or Rehab Therapists with a minimum of one year of relevant experience.
• Prefer 1 year of experience in MCO, health plan insurance environment , with expertise performing utilization management or experience working in long term care services
• Knowledge of all state and federal regulations concerning the use, disclosure, and confidentiality of all patient records.
• Analytical skills as applicable to interpret provider communication and medical records.
• Attention to detail and organizational skills.
• Ability to articulate orally and in writing an understanding of complex issues and detailed action plans, while best
• representing the organization professionally.
• Ability to work cooperatively with other employees and departments.
• Efficient and comfortable with computer electronic data entry and documentation
• Ability to succinctly document using correct spelling and grammar.
• Able to summarize from medical clinical notes, progress notes, needs assessments, functional assessments, progress notes, history and physicals , care plans and other state required documentation.
• Able to meet timelines and deadlines associated with work load.
• All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.
• Wellness
• Presbyte

Benefits

Additional Information

Location Address: 9521 San Mateo NE Albuquerque, NM 87113-2237 Compensation Pay Range: Minimum Offer $0.00 Maximum Offer $0.00 Now Hiring: LTC Utilization Management Reviewer

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