Um Clinical Care Specialist-Ltss
Current-Responsible for monitoring consumer treatment through ongoing and continuous Care Management to ensure that services are delivered based on consumer need and established clinical guidelines-Review Annual and Revised Individual Service Plans to ensure compliance through policy interpretation for Department of Health and Human Services, Innovations and Medicaid b(3) waivers for over 390 members-Monitors for undesirable performance or deviations of practice standards through care management activities that may have a negative impact on consumers. Responds through additional follow-up with consumer and providers, provider technical assistance and/or referral to other departments within the MCO-Review and revise departmental training materials as needed-Maintain consistent communication to ensure pertinent information is shared timely and appropriately regarding due process rights-Provide process improvement recommendations and suggestions that align with UM goals as a member of the UM Advisory Committee. In one year, successfully addressed Level 3 Incident reporting, streamlined the Peer Review Process and created new workflow for the AMR portal-Provide clinical guidance, coaching and informal performance training and oversight of Individual Service Plans to over 70 Care Coordinators-Ensure compliance with care management and quality improvement policies and procedures, utilization review laws and regulations, state standards-Respond to inquiries from employees regarding policies, procedures, and programs-Participate in recruitment efforts by identifying potential talent-Subject matter expert when collaborating with staff attorney regarding litigation's in addition to participation as an expert witness in Office of Administrative Hearings-Alliance CARES team member responsible for designing, organizing and implementing quarterly learning opportunities aimed at highlighting social determinants of health
