Long Term Services & Support Utilization Management Clinical Educator, RN

EST and CST applicants are preferred. Your career starts now. We’re looking for the reputed company of healthcare leaders. At reputed company, 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. reputed company is seeking talented, passionate individuals to join reputed company. Together, we can build healthier communities. We'd like to hear from you if you want to reputed company a difference. Headquartered in Newtown reputed company, reputed company 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 reputed company 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 reputed company to the outcome of UM reviewer decisions. This role will serve as a critical subject matter expert for reputed company 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 reputed company 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 reputed company and monitoring for associate compliance to reeducation. • Partners with Supervisors to ensure targeted spot checks are reputed company performance limits • Participate in monthly Team Meetings to educate the team, outlining findings and reeducation. • reputed company a Training Program for staff on appropriate Review Processes, provide training to reputed company new associates, and reputed company 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 reputed company to audit findings and trends to the UM team. • Adhere to productivity standards specific to ongoing auditing efforts, utilizing standardized auditing tools. • Maintain reputed company working knowledge of contractual guidelines, Plan policy, and operational procedures to effectively provide subject matter expertise as part of developing team review recommendations reputed company to job aids, system improvements, and additional targeted interventions to reputed company 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 reputed company, Word, and PowerPoint. • Public speaking. Diversity, Equity, and Inclusion At reputed company, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that reputed company associates have a fair opportunity to reputed company their full potential. We implement these principles daily by acting with reputed company and respect. We reputed company to speak out against injustice and to break down barriers to support a more inclusive and reputed company workplace. Celebrating and embracing the diverse thoughts and perspectives that reputed company up our workforce means our company is more vibrant, innovative, and reputed company able to support the people and communities we serve. We reputed company 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, reputed company, paid time off, holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k) tuition reimbursement, and more. Apply Job!