Service Determination Specialist II

This is a fully remote position, open to applicants in United States.

📋 Description

• Evaluate medical necessity and non-community support service healthcare reviews for authorization suitability, including home and community-based supports.

• Aid in discharge planning and care coordination for members enrolled in a CareSource Management Group line of business.

• Oversee the delivery of healthcare services in a cost-efficient manner.

• Assess the PCSP against the service requests submitted by providers to ensure precision and necessity.

• Perform front-end and back-end evaluations of services approved in Cite Auto Auth or by staff members.

• Collaborate with the provider network and Care Coordination to resolve issues arising from clinical quality audits and Cite Auto Auth reviews.

• Lead initiatives with Care Coordination on transition and discharge plans for members receiving intensive I/DD and BH treatment.

• Execute prior authorization for BH/SUD/IDD/HCBS/Waiver PASSE services.

• Handle retro-authorization requests and ongoing stay reviews.

• Partner with Medical Directors and Care Coordinators to ensure optimal service delivery.

• Utilize Evidence-Based Care systems and relevant guidelines, including MCG, ASAM, and HCBS waiver regulations.

• Stay informed about state and federal regulations, state contracts, provider agreements, benefits, and NCQA standards.

• Implement criteria and processes consistently.

• Achieve successful inter-rater reliability scores through regular audits.

• Detect and refer compliance quality issues to Quality Improvement and Network Management.

• Identify and present clinical cases to the appropriate Medical Directors for service evaluations.

• Conduct research to ensure census reports are accurate and current.

• Incorporate services and processes associated with new lines of business as required.

• Perform additional job-related tasks as assigned.

⛳️ Requirements

• A nursing degree from an accredited registered nursing (RN) program, a Bachelor’s degree in a healthcare field, or equivalent relevant work experience is mandatory.

• A current unrestricted clinical license in the state of practice as a Registered Nurse, Social Worker, Psychologist, or Clinical Counselor is essential.

• Previous experience in utilization review and/or case management related to BH/SUD/IDD/HCBS/Waiver is preferred.

• Familiarity with Medicaid, Medicare, Commercial, and Managed Care is preferred.

• Valid licensure or certification in Substance Use is preferred.

• Basic data entry skills are required.

• Proficient in Microsoft Word, Excel, and Access.

• Strong written and verbal communication skills.

• Ability to work both independently and as part of a team.

• Knowledge of the healthcare industry is beneficial.

• Proper grammar usage is a must.

• Decision-making and problem-solving capabilities are essential.

• Proper phone etiquette is required.

• Customer service orientation is important.

🏝️ Benefits

• A bonus linked to company and individual performance may be available.

• A substantial and comprehensive total rewards package is offered.

• An Equal Opportunity Employer that promotes an environment of belonging.