Utilization Management Associate Jobs in Hialeah, FL

LTSS Service Coordinator (Bilingual in Spanish/English)

Schedule: Monday-Friday 8am-5pm EST

Location: This is primarily a field based position. Candidate would need to reside in one of the following counties: Broward County

Field: This field-based role enables associates to primarily operate in the field, traveling to client sites or designated locations as their role requires, with occasional office attendance for meetings or training. This approach ensures flexibility, responsiveness to client needs, and direct, hands-on engagement. Alternate locations may be considered if candidates reside within a commuting distance from an office

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The LTSS Service Coordinator is responsible for conducting service coordination functions for a defined caseload of individuals in specialized programs. In collaboration with the person supported, facilitates the Person Centered Planning process that documents the member's preferences, needs and self-identified goals, including but not limited to conducting assessments, development of a comprehensive Person Centered Support Plan (PCSP) and backup plan, interfacing with Medical Directors and participating in interdisciplinary care rounds to support development of a fully integrated care plan, engaging the member's circle of support and overall management of the individuals physical health (PH)/behavioral health (BH)/LTSS needs, as required by applicable state law and contract, and federal requirements.

How you will make an impact:

• Responsible for performing face to face program assessments (using various tools with pre-defined questions) for identification, applying motivational interviewing techniques for evaluations, coordination, and management of an individual's waiver (such as LTSS/IDD), and BH or PH needs.

• Uses tools and pre-defined identification process, identifies members with potential clinical health care needs (including, but not limited to, potential for high-risk complications, addresses gaps in care) and coordinates those member's cases (serving as the single point of contact) with the clinical healthcare management and interdisciplinary team in order to provide care coordination support.

• Manages non-clinical needs of members with chronic illnesses, co-morbidities, and/or disabilities, to ensure cost effective and efficient utilization of long-term services and supports.

• At the direction of the member, documents their short and long-term service and support goals in collaboration with the member's chosen care team that may include, caregivers, family, natural supports, service providers, and physicians.

• Identifies members that would benefit from an alternative level of service or other waiver programs.

• May also serve as mentor, subject matter expert or preceptor for new staff, assisting in the formal training of associates, and may be involved in process improvement initiatives.

• Submits utilization/authorization requests to utilization management with documentation supporting and aligning with the individual's care plan.

• Responsible for reporting critical incidents to appropriate internal and external parties such as state and county agencies (Adult Protective Services, Law Enforcement).

• Assists and participates in appeal or fair hearings, member grievances, appeals, and state audits.

Minimum Requirements:

• Requires BA/BS degree and a minimum of 2 years of experience working with a social work agency; or any combination of education and experience which would provide an equivalent background.

• Specific education, years, and type of experience may be required based upon state law and contract requirements.

Preferred Skills, Capabilities and Experiences:

• BA/BS degree field of study in health care related field preferred.

• Bilingual in English/ Spanish strongly preferred.

• LTSS, case management, social work or hospital discharge planning experience preferred.