Under the direction of the Long Term Services and Supports (LTSS) Supervisor, the UM LTSS Clinical Reviewer is responsible for completing care and service needs reviews. Using evidence based LTSS needs assessment knowledge and clinical /social services experience, the UM LTSS Clinical Reviewer reviews Service Coordinator and Participant requests for outpatient services, working closely with Service Coordinators to collect all information necessary to perform a thorough needs review. The UM LTSS Clinical Reviewer’s will pend requests for additional information and/or request clarification. The UM LTSS Clinical Reviewer will use his/her professional and clinical judgment to evaluate the request to ensure that appropriate services are approved and recognize care and service coordination opportunities and refer those cases as needed. The UM LTSS Clinical Reviewer will apply professional and clinical judgment, clinical policies and medical management guidelines to authorize services and appropriately deny services when guidelines are not met in their professional opinion. The UM LTSS Clinical Reviewer will maintain current license, knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit’s business and uses professional judgment in their application. While denials for Medical Necessity are determined by the LTSS UM MD, denials for LTSS services will be handled by the UM LTSS Clinical Reviewer in their judgment and discretion. The UM LTSS Clinical Reviewer will understand the member’s ongoing medical conditions, triage members needs to other appropriate specialty programs, and work with HCBS services coordinator to have the plan of care reflect those medical needs.

Responsibilities:

• Receives requests for authorization of Long Term Services and Supports available and as defined in the North Carolina Tailored benefit plan. Authorization request examples include but are not limited to; Personal Assistance Service (PAS), home care (skilled) services, Adult Day services, Home Delivered Meals, Durable Medical Equipment and Environmental Modifications.
• Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination).
• Verifies and documents Participant eligibility for services.
• Communicates and interacts in a real time bases via “live” encounters with providers and appropriate others to facilitate and coordinate the activities of the Utilization Management process(es).
• Utilizes technology and resources (systems, telephones, etc.) to appropriately support work activities. Voice mail as an adjunct to the daily work activities versus major reliance for giving and receiving information from Service Coordinators.
• Accesses and applies Medical Necessity Guidelines for decision making.
• Applies submitted information to the North Carolina Tailored Plan authorization process (utilizing medical guidelines, Process Standards, Policies and Procedures, and Standard Operating Procedures). Authorizes services in accordance with medical and health benefits guidelines.
• Coordinates with the referral source if insufficient information is not available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows the Tailored plan process for requesting additional information, including recent inpatient records and diagnosis for review to support HCBS services requests
• Documents case activities for Utilization determinations and discharge planning enterprise platform systems in a real time manner (as events occur). Completes detail line as indicated.
• Provides verbal denial notification to the requesting Service Coordinator and Participant as per policy. Reviews and generates the denial letter from the LTSS UM MD in a timely manner.
• Adheres to Process Standards, Standard Operating Procedures, and Policies and Procedures, as defined by specific UM role (Prior Authorization, Concurrent Review)
• Submits appropriate documentation/clinical information in enterprise platform systems record keeping and documentation requirements.
• Recognizes opportunities for referrals back to the Service Coordination team and refers accordingly.
• Participates in Quality Reviews and Inter Rater Reliability processes and achieves performance results at or above thresholds established by management.
• Maintains awareness and complies with the North Carolina Tailored plan authorization timeliness standards as indicated in the contract. Participates in the “integrated health model” by looking at the member holistically and linking to appropriate programs (Substance use, Physical Health CM, Wellness) and recognizing disease processes and coordinating managers with the HCBS Services coordinator or other specialty Case Managers to ensure those needs are addressed in the plan of care. Examples could be hospice, custodial care, telemonitoring.

Education/ Experience:

• Bachelor’s Degree
• Registered Nurse
• 3 or more years’ experience in a related clinical or social services setting. Expertise and experience to include addressing needs of the Long Term Services and Support population preferred.