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