Manager, Clinical Health Services – LTSS Service Decision Review

Emploi pas sur LinkedIn

🕒 il y a 20 jours

⚔️ Virginia – Distant

⚔️ Virginia – Remote

💵 $87 035 - $187 460 / an

⏰ Temps Plein

🟡 Intermédiaire

🟠 Senior

👔 Manager

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CVS Health

Site WebLinkedInTous les Emplois

10 000+ employés

Fondée en 1963

⚕️ Assurance santé

🛒 Commerce de détail

🧘 Bien-être

Healthcare Insurance • Retail • Wellness

CVS Health est une entreprise américaine de premier plan dans le domaine de la santé, dédiée à l'amélioration de l'accès et de l'accessibilité financière des soins de santé. L'entreprise s'appuie sur une approche globale qui comprend les services de santé, l'assurance santé et la gestion des prestations pharmaceutiques. À travers ses filiales, telles qu'Aetna et CVS Caremark, CVS Health propose une gamme de services qui favorisent le bien-être, la gestion des maladies chroniques et une couverture abordable des médicaments prescrits. CVS Health exploite des pharmacies de proximité, fournit des services de pharmacie par correspondance et gère des programmes de médicaments spécialisés, visant à rendre les soins de santé pratiques et accessibles à tous. Animée par une mission de connecter les individus aux services de soins essentiels, CVS Health s'engage à favoriser des communautés en meilleure santé et à soutenir le bien-être de toutes les personnes.

Description

• 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.

🎯 Exigences

• 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

🏖️ Avantages

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