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Responsibilities include:
Performing care coordination services for assigned recipients eligible for home health services, such as Home Health Visits, PPEC, Personal Care Services, and/or Private Duty Nursing Services, based on contract requirements.
Using discretion to approve or validate UR or forwarding to a second-level reviewer. Providing first-level utilization review for inpatient and outpatient services requiring authorization, including Prospective, Urgent/Non-urgent, Concurrent, and Retrospective Reviews.
Completing prior authorizations promptly.
Conducting initial assessments to recommend appropriate home health assessments unless already completed during the current fiscal year.
Conducting home and/or PPEC visits as needed or required by contract.
Scheduling and leading initial face-to-face meetings in the recipient’s home or PPEC with the recipient (if able) and the parent or legal guardian.
Assessing, planning, implementing, monitoring, and evaluating the care options and services needed to meet the recipient’s healthcare needs.
Documenting assessment findings, actions, and outcomes.
Recording all communication, interventions, and follow-up tasks in the Care Coordination System within one business day.
Identifying patient care issues and making appropriate recommendations.
Collaborating with the parent or guardian and healthcare team to arrange home care needs.
Maintaining regular monthly contact (via phone or face-to-face) with the recipient and guardian to update the Plan of Care, resolve issues, and identify additional needs.
Participating in multidisciplinary team meetings to develop comprehensive care plans based on recipient needs.
Evaluating and updating the care plan as necessary, communicating changes to all involved parties.
Monitoring caseload eligibility status monthly in MMIS.
Completing Staffing Tools (Freedom of Choice) when reconsidering a recipient’s placement into a Skilled Nursing Facility.
Following guidelines for calls and visits related to SNF transitions to community settings over six months.
Serving as a resource to the community.
Seniority level
Entry level
Employment type
Full-time
Job function
Other
Industries
IT Services and IT Consulting
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