Remote Aetna Utilization Review Jobs in Raleigh, NC

This position performs professional and administrative work, primarily utilization review and utilization management to ensure economical and effective consumer service delivery by the PHIP enrolled network providers. The position is responsible for providing reviews of individualized service plans and requests for authorization of services to ensure consumers receive services in the least restrictive, most integrated setting appropriate to their individual needs. The position’s primary role is to review services for members identified as meeting ICF Level of Care and participating in the Innovations Waiver 1915 (c), Traumatic Brain Injury Waiver.

This position is fulltime remote. While there is no expectation of being in the office routinely, the selected candidate may be required to report to their Alliance local office location for business meetings as needed.

Responsibilities & Duties

Utilization Reviews and Management

• Conduct independent medical necessity reviews of service requests submitted by service providers against developed clinical guidelines within contractually mandated turn-around times
• Conduct utilization reviews to monitor adherence to clinical practice guidelines and best practice standards and to determine if services were delivered as requested
• Engage in care management activities to ensure individuals receive appropriate referral for treatment including; consumer and provider follow-up calls, case staffing with psychologists and medical staff
• Monitor consumer person-centered plans to ensure that effective treatment interventions are utilized, provide consultation to treating providers when person centered plan requires adjustments to better meet consumer needs
• Monitors and reports consumer and provider specific over/under utilization
• Conduct utilization reviews to monitor for over/under utilization

Program Operation and Management

• Identify high risk consumers and those with special health care needs for referral to Care Coordination and case escalation 
• Provide linkage, authorizations and level of care determinations, assisting providers and Care Coordinators with creative problem solving to recommend alternative approaches to care
• Ensure compliance with care management and quality improvement policies and procedures, utilization review laws and regulations, state standards 
• Promote access to appropriate, effective and quality treatment
• Monitor for undesirable performance or deviations of practice standards through care management activities that may have a negative impact on consumers
• Respond through additional follow-up with consumers and providers, provider technical assistance and/or referral to other departments within the MCO

Administrative Functions

• Notify members of adverse benefit determinations while preserving members’ Due Process rights
• Engage in routine follow-up to ensure consumers are engaged in treatment and services are being delivered as requested
• Document utilization review decisions in computerized authorization management system

Minimum Requirements

Education & Experience

Bachelor's degree from an accredited college or university in a human service field and two (2) years of full-time, post-bachelor's degree I/DD experience with the population served

Or

Bachelor's degree from an accredited college or university in a field other than human services and four (4) years of full-time, post-bachelor's degree I/DD experience

Or

Master’s degree from an accredited college or university in a human service field and one year (1) of full-time, post-graduate degree Intellectual/Developmental Disabilities (I/DD) 

Preferred:

Current and active North Carolina license as an LCSW, LCAS, LP, LPA, LMFT, LCMHC, or RN

Experience in the public Intellectual and Developmental Disability (I/DD)/TBI field is highly desired due to the complexity of the work

Experience in a Utilization Review and/or Utilization Management environment would be valuable for this employee

Knowledge, Skills, & Abilities

• Technical knowledge of general authorization principles and standard, working knowledge of State guidelines and policy related to utilization management and review
• Considerable knowledge of populations being served
• In depth knowledge of the Innovations Waiver
• Ability to use SIS evaluations in the determination of appropriate levels of care
• The ability to retrieve, communicate and present data and information both verbally and in writing required as is the ability to express or exchange ideas verbally and in writing
• Possess excellent problem-solving skills.  Must be creative, highly motivated, and able to operate successfully within a team management model
• Must have through knowledge of Diagnostic Treatment Guidelines/Protocols, Supports Needs Matrix, Authorization/Re-authorization Standards, and Utilization Management Standards
• Knowledge of prior authorization review continued stay and discharge reviews for IDD services to ensure appropriate amount and level of care for consumer
• Knowledgeable in the Supports Intensity Scale ™ and NCSNAP
• Knowledgeable of the Innovations Waiver, TBI Waiver and Intermediate Care Facilities
• Knowledge of documentation and clinical protocols for utilization purposes and case reviews for individual consumers in order to conduct chart reviews
• Knowledge of providing linkage, authorizations and level of care determinations to providers.
• Clinical knowledge of managed systems of Developmental Disabilities and Traumatic Brain Injury
• Knowledge of relationship development and collaboration with other services, providers and other agencies that also affect access and services within the system
• Knowledge of consumer information systems and data entry is essential
• Thorough knowledge of the requirements for requesting authorization for services including all documents required per the Medicaid contract, Clinical Coverage Policy 8P, Clinical Coverage Policy 8E and State funds benefit plan
• General knowledge of Utilization Review policies, procedures, and practices
• Ability to exercise judgment and discretion in resolving or routing provider inquiries/complaints/problems and/or to appropriate staff
• Ability to assess problems and coordinate resolutions of same
• Must have excellent organizational skills and possess the ability to express ideas clearly and concisely orally and in written documents
• Excellent interpersonal and communication problem solving skills
• Knowledge of utilization management techniques including ICD and CPT coding and Medicaid services and regulations
• Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) is required

Salary Range 

$29.54-$37.66/Hourly 

Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity 

 An excellent fringe benefit package accompanies the salary, which includes:   

• • Medical, Dental, Vision, Life, Long Term Disability
  • Generous retirement savings plan
  • Flexible work schedules including hybrid/remote options
  • Paid time off including vacation, sick leave, holiday, management leave
  • Dress flexibility