WellSense Health Plan
Acting as a liaison between Utilization Management, Care Management and Claims, the Long Term Support and Services (LTSS) Coordinator provides support to the cross-functional Senior Care Options (SCO) and NH Medicare Advantage product team by coordinating clinical and non-clinical data management to ensure delivery of timely and appropriate services to our members.
Our Investment In You
- Full-time remote work
- Competitive salaries
- Excellent benefits
Key Functions/Responsibilities
- Monitors SCO fax queue and worklists and prioritizes and triage SCO Prior Authorization and LTSS requests.
- Completes LTSS Utilization Management (UM) notification assessments in clinical care management documentation system and builds prior authorization
- Reviews and builds episodes for Continuation of Care (COC) services of newly enrolled SCO members, ensuring timely data entry of authorized services into the clinical care management documentation system
- Authorizes certain specified services, under the supervision of the UM Supervisor, according to departmental guidelines
- Requests additional clinical information for service requests as needed.
- Per standard workflows, forwards authorization requests that require clinical judgment to SCO UM Clinician, WellSense Medicare Advantage UM Clinician, or Supervisor, in a timely manner for review and processing
- Assists in completing SCO member and provider notification letters within mandated timeframes and established quality parameters
- Reviews and reconciles service events with unmatched claims in collaboration with care management and the claims
- Serves as the liaison among SCO UM, CM, and Claims, ensuring there are no gaps in appropriate and necessary care to the SCO membership
- Reaches out to service providers to ensure LTSS authorized services have been rendered to the SCO member, documenting in the clinical care management documentation
- Monitors the UM SCO internal mailbox and follows through on service requests for SCO members; inquiries may be received from the following departments: PA, SCO Customer Care, Pharmacy, Contracting, Care Management, Claims,
- Serves as point of contact for DME, medications, LTSS service authorizations for the SCO program, collaborating with CM, PA, Pharmacy, Vendor Management, Claims, and Customer
- Adheres to policies and procedures in order to meet performance and compliance standards and to ensure cost effective and appropriate healthcare delivery.
- Meets or exceeds position metrics andTurn-AroundTimeframes
- Supports SCO UM Clinician, Wellsense Medicare Advantage UM Clinician as needed.
- Identifies opportunities for workflow and process improvements related to the LTSS review and authorization
- Other duties as assigned
Qualifications
Education:
- Associate’s degree in a Healthcare related field or equivalent combination of education and relevant work experience
Experience Required
- At least 2 years of office experience, specifically in either a high volume data entry office, customer service call center, or health care office administration department
- 2 or more years of healthcare experience
- Experience with health plan utilization/claims in a provider or payer
- Prior customer service experience
- Computer work experience that required active use of 2 or more software programs
Experience Preferred/Desirable
- Prior health plan experience
- Experience with FACETS or clinical care management documentation systems or other, electronic medical records, other healthcare databases
- Experience with Medicaid/SCO population and LTSS
- Bilingual skills, fluency in Spanish
Competencies, Skills, And Attributes
- Ability to use healthcare clinical systems for documentation purposes; ability to effectively navigate systems
- Excellent customer service and diplomacy skills
- Ability to successfully collaborate across various functional departments and external constituents such as medical and other service providers
- Ability to process a high volume of requests with a 95% or greater accuracy rate
- Process improvement skills
- Strong oral and written communication skills
- A strong working knowledge of Microsoft Office products, including Excel
- Ability to successfully organize and manage projects
- Detail oriented
Working Conditions And Physical Effort
- Work is normally performed in a remote work environment
- No or very limited physical effort No or very limited exposure to physical risk
- Regular and reliable attendance is an essential function of the
About WellSense
WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.
Required Skills
Required Experience
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