Remote Manager Long Term Services & Support Utilization Management Review (RN)

Job Overview

  • Clinical License RN
  • State(s) Nationwide

Your career starts now. We are looking for the next generation of health care leaders.

At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nations leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to hear you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.

This position manages all elements of the Community HealthChoices Long Term Services and Supports (LTSS) Review Utilization Management program and staff under the supervision of the Director, LTSS Clinical Services. This includes, but is not limited to functions related to medical necessity determinations, concurrent and other clinical and medical management programs. This position will oversee LTSS UM Review for other lines of business as necessary.

  • Direct activities of the LTSS Review Utilization Management staff. Oversee staff performance with regard to medical necessity determinations, concurrent review, continuity of care, care coordination, and other clinical and medical management programs. These responsibilities extend to Community HealthChoices long term services and supports.
  • Ensure effective daily operations of the LTSS Review Utilization Management Department utilizing all applicable statutory provisions, contracts, agreements, and established policies and administrative procedures.
  • Maintain optimal staffing patterns based on contractual obligations and current LTSS Review Utilization Management budget. Comply with all policies and procedures for personnel requisitions, interviews and employment. Maintain accurate position control and organizational charts of assigned departments.
  • Prepare reports and conduct analysis of operations / services as required by departmental, corporate, regulatory, and State requirements. Work collaboratively with Information Services Department on identifying required data for reporting.
  • Assist in preparation, coordination, and follow up of LTSS Review Utilization Management audits, such as readiness review and site visits, pertaining to the LTSS Review Utilization Management Department.
  • Establish performance and productivity requirements and communicate expectations to management team. Work collaboratively with Supervisor in identification of individual and / or group deficiencies in scheduled Performances Reviews. Establish action plan for assessment and resolution of identified issues.
  • Identifies systemic performance gaps and develops curriculum to address areas of concern.
  • Comply with Corporate, Federal, and State confidentiality standards to ensure the appropriate protection of member identifiable health information.
  • Works in collaboration with the Director, LTSS Clinical Services in creating operational and strategic plans for the department.
  • Creates and supports an environment that fosters teamwork, cooperation, respect, and diversity.

Education/ Experience:

  • Bachelor’s Degree.
  • Registered Nurse.
  • Must be a licensed registered nurse,  physician or physician’s assistant.
  • Minimum 3-5 years of previous people leadership experience.
  • Valid Driver’s license and clean driving record required; reliable transportation and appropriate auto insurance necessary.
  • Demonstrated ability to assess department’s work quality and develop/implement process improvements to achieve contractual and oversight compliance.
  • Demonstrated competency in use of healthcare data.
  • 3 years LTSS case management experience in relevant scope preferred, one year required.
  • Excellent analytical and problem solving skills.
  • Strong computer skills.  Proficiency and speed working in all Microsoft office Suite applications.
  • Experience working with the aged, blind, and/or disabled population strongly desired.
  • Understanding of and expertise in quality improvement and medical economics.

Diversity, Equity, and Inclusion

At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

 

 

 

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