Complex Population, Service Determination Specialist II

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