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

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.