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Foster Care Clinical Performance Monitoring Specialist - Louisville or Lexington, KY

Company: WellCare
Location: Louisville
Posted on: March 28, 2020

Job Description:

Responsible for oversight and coordination of state contract required DCBS Peer to Peer review process. Coordinates with Utilization Management, Care Management and WellCare State Medical Director medical necessity initial and concurrent review outcomes for foster children in behavioral health acute level and residential level of care. Reviews medical necessity review findings and DCBS Peer to Peer form to ensure contract requirements are followed and clinical documentation is ready for state review. Tracks and monitors outcomes, trends. Identifies potential concerns that may lead to regulatory compliance issues. REPORTS TO: Sr Mgr, Foster Care, Adoption and Adult GuardianshipDEPARTMENT: Kentucky Care ManagementMAIN OFFICE LOCATION: Louisville or Lexington, KentuckyJOB TYPE: Salary/ExemptEssential Functions: Conducts Care Management (UM, BH, CM) clinical file assessments by reviewing clinical documentation as assigned for DCBS Peer to Peer review process. Utilizes clinical knowledge and experience to evaluate documentation of medical necessity initial and concurrent reviews, DCBS Peer to Peer form, and assess if contract requirements for DCBS Peer to Peer are met. Coordinates weekly meetings with Utilization Management, Care Management, and WellCare State Medical Director and others to discuss upcoming medical necessity reviews and determine if criteria for DCBS Peer to Peer are met or if continued approval of clinical services is appropriate. Appropriately escalates areas of concern identified during clinical reviews. Coordinates peer to peer discussions between WellCare State Medical Director and DCBS/DMS/DBHDID Medical Director. Tracks data generated by the DCBS Peer to Peer process, identifies trends/potential issues, and reports to leadership findings. Participates as needed with preparation for State, CMS, and NCQA audits by collecting and /or reviewing clinical areas of relevance. Follows departmental guidelines and processes. Peform other duties as assigned. Additional Responsibilities: Candidate Education: Required A Master's Degree in Social Work, Counseling, Nursing, related clinical field Candidate Experience: Required 3 years of experience in Kentucky Foster system, private child care, behavioral health acute/psychiatric residential treatment facility Required 5 years of experience in Behavioral HealthPreferred 1 year of experience in Managed Care Candidate Skills: Intermediate Ability to effectively present information and respond to questions from peers and management Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions Intermediate Demonstrated time management and priority setting skills Intermediate Demonstrated written communication skills Intermediate Demonstrated interpersonal/verbal communication skills Intermediate Ability to create, review and interpret treatment plans Intermediate Ability to effectively present information and respond to questions from peers and management Intermediate Ability to communicate and make recommendations to upper management Advanced Ability to work as part of a team Intermediate Ability to represent the company with external constituents Intermediate Other Ability to assess clinical documentation in relation to contract required DCBS Peer to Peer process and make recommendations and decisions based on documentation. Licenses and Certifications: A license in one of the following is required: Required Other A license in one of the following is required Required Licensed Registered Nurse (RN) Required Licensed Clinical Social Worker (LCSW) Required Licensed Mental Health Counselor (LMHC) Required Licensed Marital and Family Therapist (LMFT) Preferred Certified Case Manager (CCM) Technical Skills: Required Intermediate Microsoft Excel Required Intermediate Microsoft Outlook Required Intermediate Microsoft Word Preferred Intermediate Healthcare Management Systems (Generic) Languages: About usHeadquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.

Keywords: WellCare, Louisville , Foster Care Clinical Performance Monitoring Specialist - Louisville or Lexington, KY, Healthcare , Louisville, Kentucky

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