Specialist, Care Management Oversight

ABOUT US

Join us in making a career in Independent Living Systems, an industry leader in managing home and community-based programs for over 20 years. Independent Living Systems, LLC and its subsidiaries offer a comprehensive range of clinical and third-party administrative services to managed care organizations and providers that serve high-cost, complex member populations in the Medicare, Medicaid, and Dual-Eligible Market. ILS provides tailored integrated solutions aimed at improving health outcomes while rebalancing costs, addressing social determinants of health and connecting members with community-based resources.

Position Summary

The primary role of the Specialist, Care Management Oversight is to evaluate and review requests for Long-Term Services and Supports (LTSS) to ensure compliance with program requirements, as well as state and federal regulations. This position involves assessing service requests from members or their authorized representatives, reviewing comprehensive and supplemental assessments—including caregiver adequacy assessments—and examining relevant medical and clinical documentation when applicable, to verify the appropriateness and necessity of the requested services.

The Specialist, Care Management Oversight collaborates closely with the Medical Director(s), who holds the ultimate responsibility for making final determinations regarding the medical necessity of the requested services.

Essential Functions 

1. Service Request Review: Evaluate service requests submitted by members or their authorized representatives using various tools, including the applicable HRA and supplemental assessments, Caregiver Adequacy assessment, and the Home and Community-Based tool. Ensure that assessments, tools, and documentation are current, precise, and accurately reflect the member's condition.
2. Collaboration with Care Managers: Work closely with care managers to gather additional information regarding the member’s care needs, as applicable.
3. Task Review and Processing: Review and process all tasks in the Supervisor Review queue, including new service requests and those related to authorization extensions. Reviews must be done timely and efficiently to ensure adherence to established timelines. Standard authorizations decisions must be provided within no more than six (6) days following receipt of the request for service.
4. Medical Director Consultation: Refer cases to the Medical Director for final determination when the member’s current situation and conditions do not justify the service request.
5. ICT Meeting Coordination: Coordinate and facilitate ad-hoc Interdisciplinary Care Team (ICT) meetings to review complex cases that require a multidisciplinary approach. These meetings ensure appropriate care is provided while safeguarding the members’ choice of living arrangements when safe and suitable.
6. Trend Identification and Improvement: Identify trends and opportunities for improvement at the department, team, and individual levels regarding the care planning process. Immediately communicate findings to the Director of Care Management Oversight and actively contribute to the development and implementation of action plans as needed.
7. LTC Program Compliance: Stay up to date on Long-Term Care (LTC) program requirements.
8. Performs other duties as required or assigned.

Education and Experience

• Bachelor’s degree in social work, sociology, psychology, gerontology, or related social services field or
• Registered nurse licensed to practice in the state.
• Five (5) to Seven (7) years of experience in Medicaid and LTSS is required.

Required Skills

1. Technical and analytical skills:

• Clinical Knowledge: In-depth understanding of Long-Term Services and Supports (LTSS), including assessments like 701B/T, LTC Supplemental Assessment.
• Regulatory Compliance: Strong knowledge of the SMMC – LTC Contract and the SMMC Long Term Care Program Coverage Policy.
• Medical Documentation Review: Ability to accurately review and interpret medical and clinical documentation to assess the appropriateness of service requests.

2. Communication and interpersonal skills:

• Collaboration: Ability to work effectively with care managers, Medical Directors, and other healthcare professionals to gather information and make informed decisions.
• Decision-Making: Strong judgment skills, particularly in assessing when to escalate cases for final determination by the Medical Director.

3. Organizational and management skills:

• Task Management: Capability to manage and prioritize tasks, including processing service requests and handling the Supervisor Review queue efficiently to ensure adherence to the established timeframes.
• Attention to Detail: Ensuring all documentation, tools, and assessments are up-to-date and accurately reflect the member’s current condition.
• Process Improvement: Ability to identify opportunities for improvement and contribute to the development of action plans

4. Technical skills: Proficiency with Microsoft Office suite. Efficient typing skills. Ability to familiarize and become proficient with ILS’s care management platform: eCare.

5. Adaptability: Willingness to stay updated on LTC program requirements and adapt to changes in regulations and best practices.

6. Problem-Solving: Ability to approach complex cases with a multidisciplinary perspective to ensure optimal outcomes for members.

7. Customer Focus: Dedication to ensuring that members' needs are met while respecting their preferences and choices regarding care and living arrangements.

EEO STATEMENT 

In compliance with the Drug-Free Workplace Act of 1988, Independent Living Systems has a longstanding commitment to provide a safe, quality-oriented, and productive work environment. Alcohol and drug abuse pose a threat to the health and safety of ILS employees and to the security of the company's equipment and facilities. For these reasons, ILS is committed to the elimination of drug and alcohol use and abuse in the workplace. Independent Living Systems, LLC, and its subsidiaries, including FCC, provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, disability, ancestry, or any other characteristic protected by state, federal, or local law. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.