Utilization Management Reviewer-Long Term Care

Overview

Now hiring a Utilization Management Reviewer-Long Term Care

Responsible for conducting Nursing (NF) Facility Level of Care (LOC) determinations according to state regulations and criteria. Performs utilization review activities to ensure that services rendered to members meet Long Term Care Supports and Services (LTSS) criteria and services are delivered in the appropriate setting. Utilizes LTSS skills and established criteria to review, coordinate, document and approve all aspects of the utilization/benefit management program, including but not limited to community benefit care plans and self-directed community benefit care plans and budgets. Validates and interprets documentation using approved LTSS criteria. Consults with PHP medical directors and refers for medical director decisions on cases not meeting LTSS criteria, NF LOC denials and care plans that result in a reduction in service or benefit denial. Refers cases for Quality Management review and Special Investigative Review as indicated for quality of care issues and possible abuse/fraud

How you belong matters here.

We value our employees' differences and find strength in the diversity of our team and community.

At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.

Why Join Us

• Full Time - Exempt: Yes
• Job is based Rev Hugh Cooper Admin Center
• Work hours: Days
• Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees.

Qualifications

• Active Nursing license in NM or compact license (RN or LPN) with a minimum of one year of relevant experience; or
• 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.

Responsibilities

• 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).
• Documents recommendations and NF LOC determinations (approvals, request for more information and denials in PHPs case management system, including appropriate documentation of authorization and NF LOC begin and end date eligibility spans according to established HSD policies. Refers all NF LOC denials to the health plans medical director for review.
• 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.
• Generates and maintains documentation of all appropriate notice of actions, communication forms, and notification forms and other provider and member notification letters and communication to comply with HSD requirements.
• Reviews changes and updates to community benefit care plans and budgets based upon a significant change in condition or status.
• Advises manager of possible trends in inappropriate utilization (under and/or over), and other quality of care issues.
• Communicates effectively with providers, PHP medical directors, PHP/PIC departments, care coordinators, HSD and applicable PHS departments as evaluated through supervisory audits, satisfaction surveys, and 360 evaluations, as applicable.
• Meets departmental and/or regulatory turnaround times for long term care utilization management and NF LOC determinations, while maintaining productivity and quality standards.
• Assists with preparing documentation for audits, as appropriate.
• Performs other functions as required.

Benefits

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 Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian? As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

Inclusion and Diversity Our culture is one of knowing and respecting our patients, members, and each other. We capture this in our Promise and CARES commitments.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

Maximum Offer for this position is up to USD $44.49/Hr. Compensation Disclaimer The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.

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