Clinical - LTSS Service Care Manager

3 weeks ago

Round Rock, United States Axelon Services Corporation Full time
Location: Remote - Texas, preferably Central SDA

SHIFT: M - F 8am - 5PM

Duration: 6+ Month contract

*This is a Social Worker position. They will support the Star Plus Waiver member population. The position is remote; however, it's preferred that they are located in or near the Central SDA. Preferred work experience: Medicaid MCO.

Walk me through the day-to-day responsibilities of this the role and a description of the project:
  • Review assessments & service plans (internal assessments)
  • Follow up on pending assessment findings, clarify DX, reported abnormal findings, requested referrals, etc.
  • MN denials
    • Research community resources.
  • 2065D approval/denials
    • Update LTSS
    • Terminate LTSS waiver service authorizations.
    • Provide community resources.
    • Instruct member on appeal process and level change.
  • ISP updates (internal), 1700-3 obtain verbal approval and update form, update 1700-2 with waiver items.
  • Initiate LTSS/acute services (create authorization request template)
  • Research complaints and provide updates to managers for complaint responses.
  • Escalations
    • MSC call backs.
  • CDS review
  • Acute UM denials to include PT denial, request for more information.
  • Create clinical reviews/IRTs
  • CIC, CIS without MNLOC completion.
  • Fair hearing assistance as needed.
  • Determine MN for post assessment identified items.
  • Dental, nursing, vision, verify service utilization, 28 day follow ups.
    • Verify all services have been started.
    • Follow up on all non DME identified needs.
  • Send required referrals for new services/items identified except DME.
    • Submit DME tasks for newly identified DME items.

Describe the performance expectations/metrics for this individual and their team:
  • Review monthly audits and weekly calls to ensure we are meeting contractual requirements.

Job Description: "Position Purpose:
Assists in developing, assessing, and coordinating holistic care management activities to enable quality, cost-effective healthcare outcomes. May develop or assist with developing personalized service care plans/service plans for long-term care members and educates members and their families/caregivers on services and benefits available to meet member needs.

Education/Experience:
Requires a Bachelor's degree and 2 4 years of related experience. Internal/External Groups with which the Candidate will interface: Required Skills/Experience: Preferred Skills/ Experience: 1. Excellent computer skills 1. Previous MCO experience 2. Proficient in Microsoft programs, i.e.. Word, Excel, and OneNote 2. 3. 3. Education Requirement: BS-Social Worker Education Preferred:

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