LTSS Coordinator II

Job Summary:

The LTSS Coordinator II monitors and promotes effective utilization of long term services and supports through clinical review and benefits management

Essential Functions:

• Acts as point of contact with the Primary Care Manager, Medical Director, Provider, or other internal/external stakeholders to function in a collaborative role as a member of the interdisciplinary care team (ICT) to support coordination of long-term services and supports Ensures timely level of care completion and/or HCBS enrollment/disenrollment and/or review of HCBS services including home modification to maintain compliance with regulatory and accreditation regulations
• Verifies eligibility, previous enrollment history, and demographics of members during case reviews
• Completes prospective and retrospective review of requests for NF level of care determinations, respite care, waiver services, home modifications, and/or durable medical equipment per established processes
• Coordinates, oversees, and provides input in the clinical documentation system for the issuance of approvals and denials of LTSS services
• Responsible for clinical functions related to issuance of LTSS approvals and denials; supports appeals processes as requested
• Coordinates with the Care Manager and/or providers to gather clinical documentation to complete LTSS reviews
• Coordinates care with internal and external case management team members, providers, and/or other stakeholders to facilitate NF discharge planning in a timely and cost-effective manner
• Reviews current documentation of contacts, treatment plans, case notes, referrals, and assessments in the electronic medical record according to current accreditation and compliance guidelines
• Assists with development and implementation of updated care plans, by defining specific issues, prioritized goals and interventions as agreed to by all parties
• Documents, identifies and communicates with Health Partners, Care Managers, Medical Directors, Discharge Planners, Providers and/or other stakeholders as needed for care coordination and to establish safe discharge plans between levels of care when clinically appropriate
• Closely collaborates with case management for any identified changes in eligibility for a member’s assessed level of care and/or with any changes in level of care determinations identified by providers or other external stakeholders
• Maintains knowledge of federal and state regulations governing CareSource, State Contracts and Provider Agreements, and CareSource Medicare and Medicaid benefits (including HCBS and nursing facility-based services). Attends and participates in interdisciplinary team meetings, State Hearings, and/or Medical Advisement meetings, when requested
• Escalates identified care coordination needs to the appropriate case management team member(s) and leader(s)
• Identifies and refer quality issues to Quality Improvement
• Maintains appropriate documentation following protocols and guidelines of the MyCare Program
• Precepts and/or mentors new staff
• Participates in special projects or research, as requested
• Maintains required reporting and assists with data analysis, as requested
• Performs other job duties, as requested

Education and Experience:

• Completion of an accredited Registered Nurse (RN) degree program or degree required to obtain Social Worker licensure in the state of Ohio is required
• Bachelor’s Degree in Nursing (BSN) or equivalent baccalaureate degree in healthcare field is preferred
• Minimum of three (3) years of experience in case management and/or managed care is required
• Experience in a Medicare and/or Medicaid managed care environment is preferred
• Post-acute, home care, waiver, or acute clinical care experience is preferred

Competencies, Knowledge and Skills:

• Intermediate proficiency in Microsoft Office Suite
• Basic level knowledge of a Windows based environment
• Ability to operate smart phone, iPad, or other mobile communication devices to ensure productivity and ability to perform essential functions
• Excellent written and verbal communication skills
• Demonstrated ability to work with diverse populations in a non-judgmental manner 
• Ability to work independently and within a team
• Strong organizational skills
• Excellent assessment skills 
• Attention to detail
• Knowledge of Medicare and Medicaid
• Critical thinking and listening skills
• Time management skills
• Customer service oriented
• Decision making/problem solving skills
• Knowledge of evidence-based medical criteria and/or standards of care

Licensure and Certification:

• Current, unrestricted Registered Nurse (RN)Licensed Social Worker (LSW), or Licensed Independent Social Worker (LISW) licensure in the state of Ohio is required
• Case Management Certification (CCM) is preferred

Working Conditions:

• Alternate work location or work from home position 
• Attendance at in-person meetings may be required 
• May be required to sit/stand for long periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business