Location: Remote, Texas, preferably Nueces SDA Shift: M - F 8am – 5pm Duration: 6+ months *This is a Social Worker position. They will support the Star Plus Waiver member population. The position is remote; however, it's preferred that they are located in or near the Nueces SDA. Preferred work experience: Medicaid MCO. Walk me through the day-to-day responsibilities of this the role and a description of the project
- Review assessments & service plans (internal assessments)
- Follow up on pending assessment findings, clarify DX, reported abnormal findings, requested referrals, etc.
- MN denials
- Research community resources.
- 2065D approval/denials
- Update LTSS
- Terminate LTSS waiver service authorizations.
- Provide community resources.
- Instruct member on appeal process and level change.
- ISP updates (internal), 1700-3 obtain verbal approval and update form, update 1700-2 with waiver items.
- Initiate LTSS/acute services (create authorization request template)
- Research complaints and provide updates to managers for complaint responses.
- Escalations
- CDS review
- Acute UM denials to include PT denial, request for more information.
- Create clinical reviews/IRTs
- CIC, CIS without MNLOC completion.
- Fair hearing assistance as needed.
- Determine MN for post assessment identified items.
- Dental, nursing, vision, verify service utilization, 28 day follow ups.
- Verify all services have been started.
- Follow up on all non DME identified needs.
- Send required referrals for new services/items identified except DME.
- Submit DME tasks for newly identified DME items.