Job Summary:
Complex Population Service Determination Specialist II is responsible for processing medical necessity and noncommunity supports and service health care reviews for appropriateness of authorization to include home and community-based supports. This role assists with discharge planning activities and care coordination for members enrolled with a CareSource Management Group line of business, as well as monitoring the delivery of healthcare services in a cost-effective manner.
Essential Functions:
Compares PCSP to service request submitted by provider to ensure accuracy and need for services
Conducts front and back end reviews of services approved in Cite Auto Auth or by staff
Works with provider network and Care Coordination to communicate and address provider concerns resulting from clinical quality audits and/or cite auto auth reviews
Leads collaboration with Care Coordination on transition and discharge plans for members receiving highest levels of I/DD and BH treatment
Responsible for the prior authorization of BH/SUD/IDD/HCBS/Waiver PASSE services.
Responsible for retro-authorization requests and continued stay reviews
Collaboration with Medical Directors and Care Coordinators to ensure the best service is in place
Familiar with Evidence Based Care systems such as MCG, ASAM, HCBS waiver guidelines
Maintain knowledge of state and federal regulations governing CareSource, state contracts, provider agreements, benefits, and NCQA standards
Consistent application of criteria and processes
Successful Inter-rater reliability scores evidenced by routine audits
Identify and refer compliance quality issues to Quality Improvement and Network Management
Identify and present (verbal or written) clinical cases to the appropriate Medical Directors for appropriate determination of the requested service
Conducts research to ensure census reports are accurate and up to date
Perform any other job-related instructions, as requested including adding services and processes related to the development of new lines of business
Perform any other job duties as requested
Education and Experience:
Nursing degree from an accredited registered nursing (RN) program or Bachelor’s degree in a health care field or equivalent years of relevant work experience is required
Prior experience in utilization review and/or case management working with BH/SUD/IDD/HCBS/Waiver is preferred
Experience with Medicaid, Medicare, Commercial and Managed Care is preferred
Competencies, Knowledge and Skills:
Basic data entry skills
Knowledge of Microsoft Word, Excel and Access
Communication Skills; written and verbal
Ability to work independently and within a team environment
Familiarity of the healthcare field
Proper usage of grammar
Decision making/problem solving skills
Proper phone etiquette
Customer service oriented
Licensure and Certification:
Current unrestricted clinical license in state of practice as a Registered Nurse, Social Worker, Psychologist or Clinical Counselor is required
Valid licensure or certification in Substance Use preferred
Working Conditions:
General office environment; may be required to sit or stand for extended periods of time
Compensation Range:
$56,430.00 - $90,360.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Hourly
Organization Level Competencies
Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business
This job description is…