Long Term Services & Support Utilization Management Clinical Educator, RN

Location: Philadelphia, PA

Primary Job Function: Medical Management

ID**: 37863

EST and CST applicants are preferred.

Your career starts now. We’re looking for the next generation of healthcare leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. We'd like to hear from you if you want to make a difference.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with over 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.

As part of the Community Health Choices LTSS Utilization Management (UM) Review Team, the [ design title] is responsible for conducting daily and weekly associate oversight and internal auditing processes while providing high-level expertise and analysis to the Community Health Choices (CHC) UM department to mitigate the risk of noncompliance related to the outcome of UM reviewer decisions. This role will serve as a critical subject matter expert for all CHC LTSS UM review activities and conduct ongoing standardized quality monitoring reviews specific to UM activities to ensure appropriate decisions occur while following state-mandated decision methodology. This role identifies missed opportunities during the LTSS UM Review process and implements mitigation re-education to associates to improve review outcomes in the future by using targeted reeducation.

Principal Accountabilities:

• Review data weekly to monitor associate performance and work with current Supervisors to direct spot checks and address missed opportunities for reductions.

• Facilitates and monitors specific associate review outcomes using internal auditing processes, from identifying pertinent Participant records to overseeing remediation requirements.

• Provides targeted reeducation for associates and supervisors for quick remediation regarding decision outcomes.

• Provides ongoing oversight and monitoring for associate compliance to reeducation.

• Partners with Supervisors to ensure targeted spot checks are within performance limits

• Participate in monthly Team Meetings to educate the team, outlining findings and reeducation.

• Develop a Training Program for staff on appropriate Review Processes, provide training to all new associates, and develop an Anytime Learning curriculum, as identified.

• Development of audit tools to enhance documentation standards throughout CHC.

• Responsible for participating in process improvement initiatives, including providing educational materials related to audit findings and trends to the UM team.

• Adhere to productivity standards specific to ongoing auditing efforts, utilizing standardized auditing tools.

• Maintain current working knowledge of contractual guidelines, Plan policy, and operational procedures to effectively provide subject matter expertise as part of developing team review recommendations related to job aids, system improvements, and additional targeted interventions to achieve and maintain team program performance and contract adherence.

Education/Experience:

• Bachelor’s Degree required.

• Registered Nurse required.

• 1 to 3 years experience in Quality Review Auditing

• 1 to 3 years experience educating teams

• 1 to 3 years medical record review

Other Skills:

• Critical thinking skills.

• Technically proficient.

• Proficient in MS Excel, Word, and PowerPoint.

• Public speaking.

Diversity, Equity, and Inclusion

At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We implement these principles daily by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

Our Comprehensive Benefits Package

Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k) tuition reimbursement, and more.

EOE Minorities/Females/Protected Veterans/Disabled