Manager, Clinical Health Services – LTSS Service Decision Review

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🕒 Maio 22

⚔️ Virginia – Remoto

⚔️ Virginia – Remote

💵 $87.035 - $187.460 / ano

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

👔 Gerente

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CVS Health

SiteLinkedInTodas as Vagas

10.000+ funcionários

Fundada em 1963

⚕️ Seguro de Saúde

🛒 Varejo

🧘 Bem-estar

Healthcare Insurance • Retail • Wellness

CVS Health é uma empresa líder de saúde nos Estados Unidos, dedicada a ampliar o acesso e a acessibilidade ao cuidado. A empresa adota uma abordagem abrangente que inclui serviços de saúde, seguro saúde e gestão de benefícios farmacêuticos (PBM). Por meio de suas subsidiárias, como Aetna e CVS Caremark, a CVS Health oferece uma variedade de serviços que promovem o bem-estar, a gestão de condições de saúde e a cobertura acessível de medicamentos prescritos. A CVS Health opera farmácias de bairro, oferece serviços de farmácia por correspondência e gerencia programas de medicamentos de especialidade, com o objetivo de tornar o cuidado com a saúde conveniente e acessível para todos. Movida pela missão de conectar pessoas a serviços essenciais de cuidado, a CVS Health está comprometida em fomentar comunidades mais saudáveis e apoiar o bem-estar de todas as pessoas.

Descrição

• Provides direct leadership and oversight of LTSS service authorization and decision review operations, including initial, concurrent, and retrospective reviews. • Ensures compliance with DMAS requirements, contractual obligations, CMS regulations, and internal medical management policies. • Oversees timely and accurate issuance of Notices of Action, ensuring regulatory timeframes, content, and member rights are met. • Leads and supports appeal review processes, including preparation of clinical rationales, file reviews, and collaboration with Medical Directors and Appeals teams. • Establishes and monitors performance expectations related to productivity, timeliness, quality, and compliance outcomes. • Recruits, hires, coaches, and develops staff, supporting a culture of accountability, consistency, and continuous improvement. • Utilizes data and audit findings to identify trends, risks, and opportunities for process improvement. • Escalates quality, compliance, and regulatory concerns through established governance channels. • Serves as a clinical resource and subject matter expert for LTSS service authorization policy interpretation. • Communicates effectively with internal and external stakeholders, including state partners, in both written and verbal formats. • Leads change initiatives and process enhancements to improve member experience, decision accuracy, and operational efficiency. • Ensures all administrative and people management responsibilities are completed in accordance with company standards.

🎯 Requisitos

• Active and unrestricted Virginia Registered nurse license • 5+ years of clinical experience • 3+ years of LTSS service authorization, utilization management, or service decision review experience • 2+ years of supervisory or people leadership experience • Demonstrated knowledge of LTSS service authorization criteria, Notice of Action requirements, and member appeal rights • Experience with Medicaid programs and DMAS Medicaid Enterprise System (MES) • Strong analytical skills with the ability to interpret data and apply findings to operational improvements • Proficiency with MS Office applications and virtual work environments

🏖️ Benefícios

• medical, dental, and vision coverage • paid time off • retirement savings options • wellness programs • other resources, based on eligibility