Utilization Management Coordinator (RN, MSW, OT, PT)

About the role

Community LIFE is a program of all-inclusive care for the elderly, committed to empowering older adults to remain at home while preserving their dignity, independence and quality of life. Our program brings the region’s experts in geriatric medicine and care together to work as a team in specialized Day Centers, to help older adults enjoy the highest quality of life possible. Our professionals are committed to keeping older adults independent, and in their homes. Our wide range of services are designed to meet the varied needs of seniors, and include medical care, social services, meals, activities, transportation and much more.

Responsibilities

• Perform/coordinate utilization management functions across all levels of care.
• Support the established hospital & nursing facility service authorization process by adhering to utilization management protocols and guidelines.
• In compliance with Community LIFE policies, industry standards, medical criteria and necessity, recommend and coordinate clinically sound and consistent level of care coverage decisions to assure delivery of the “right care at the right time in the right location.”
• Interpret clinical information provided or reviewed and work closely with RN Case Managers (RNCM) to ensure participant goals of care are known to health care providers across the continuum and at each transition of care.
• Demonstrate experience across diverse healthcare settings, including skilled nursing facilities, community-based home care, outpatient clinics and hospital environments.

Requirements

• Bachelor degree in Nursing (BSN) or equivalent with valid Registered Nurse (RN) licensure in Pennsylvania
• Bachelor degree in Physical Therapy with valid Physical Therapist (PT) Licensure in Pennsylvania
• Associate degree in Physical Therapy with valid Physical Therapist Assistant (PTA) Licensure in Pennsylvania
• Bachelor degree in Occupational Therapy with valid Occupational Therapist (OT) Licensure in Pennsylvania
• Associate degree in Occupational Therapy Assistant with valid Occupational Therapist (COTA/L) Assistant Licensure in Pennsylvania
• Masters of Social Work (MSW)
• Valid PA Driver’s license

Qualifications

• Minimum of 3 years in each of the below areas: Utilization review, utilization management, and/or insurance-based case management and authorization process.
• Discharge planning and coordination of post-acute care needs.
• Collaboration with interdisciplinary teams across clinical and community-based settings.
• Prior experience within a PACE program is preferred.

Skills

• Ability to interpret clinical information to support utilization protocols for authorizing inpatient services.
• Computer skills including Outlook, Word, PowerPoint and Excel.
• Self-organization skills; attentiveness to detail and accuracy.
• Knowledge of current acute and long-term care utilization standards.
• Ability to accept and utilize guidance.
• Ability to assess, address, and develop effective solutions for complex participant cases and care needs.
• Ability to review clinical documentation, identify trends, recognize gaps in care, and evaluate participant needs to support appropriate utilization management decisions.
• Ability to apply clinical knowledge to assess participant care needs, determine medical necessity, and support appropriate levels of care and service authorization.
• Flexibility in responding to changes in departmental processes, regulatory requirements, participant needs, and daily workflow demands.
• Ability to effectively manage multiple high-priority cases, competing demands, and time-sensitive deadlines in a fast-paced environment.
• Ability to proactively identify barriers, care gaps, and opportunities for process improvement while recommending appropriate interventions to support participant outcomes.
• Ability to respectfully and effectively interact with providers, case managers, and other members of the internal IDT for Community LIFE and outside vendors.
• Ability to compile and report data in a meaningful way.
• Acceptable physical and mental health to carry out the responsibilities of the position.