LOCATION: Remote

SALARY: Depending on qualifications & experience of candidate. This position is non-exempt and is eligible for overtime compensation.

GENERAL STATEMENT OF JOB:

The Intellectual and Developmental Disabilities (I/DD) Care Reviewer is responsible for facilitating the review of service plans and service authorization requests to ensure that individuals are receiving the most appropriate services at a given time. The I/DD Care Reviewer screens authorization requests for completeness, approves or administratively denies some requests based on review check-sheets, and refers requests that cannot be approved to I/DD Utilization Management Clinicians, Care Coordinators or other appropriate individuals when service provision is inconsistent with the approved plan.

Note: This position requires access to and use of confidential healthcare information or protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Alcohol and Substance Abuse Patient Records law, 42 CFR Part 2, and various state laws. As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his/her capacity as an employee of Vaya Health. The individual filling this position shall also sign a confidentiality statement as an employee of Vaya Health.

ESSENTIAL JOB FUNCTIONS:

Review of Service Plans and Authorization Requests:

• Ensure that all required documents are submitted with Service Plans and Authorization Requests for specific benefit plans

o Review of plan and service requests for completeness

o Collection and transfer of non-clinical data

o Gather clinical information but does not engage in the evaluation or interpretation of clinical information

o Consults with licensed clinical staff when performing initial screening activities of needed

• Approve requests and plans based on review check-sheets
• Refer plan and authorization requests that cannot be approved to I/DD UM Clinicians

Monitor the Delivery of Monitored Services

• Identify provider/ Care Coordinator training needs; provide training as needed and requested
• Identify and document service gaps and deficiencies in access to services
• Contact providers to gather information about the delivery of services between authorization reviews

o Where providers report service provision inconsistent with the plan, forward in formation to a I/DD UM Clinicians or Care Coordinator.

Additional Reviews

• Participation in Post Payment Review or other quality assurance reviews as requested.

Other Duties as Assigned

QUALIFICATIONS & EDUCATION REQUIREMENTS:

A Bachelor’s degree in special Education, Psychology, Social Work or closely related Human Services area and 2 year of post-degree professional experience. Must quality as a QP for Developmental Disabilities.

PHYSICAL REQUIREMENTS:

Person in this position is required to have close visual acuity to perform activities that include viewing a computer terminal; and extensive reading. Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers. Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.

KNOWLEDGE, SKILL & ABILITIES:

• A demonstrated knowledge of the assessment and treatment of developmental disabilities, with or without co-occurring mental illness, is a necessity. Additionally, the incumbent should be able to learn and understand legal, waiver and program practices/requirements and apply this knowledge in problem-solving and responding to questions/inquiries.
• This position requires exceptional interpersonal skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts and established processes. Problem solving, negotiation and conflict resolution skills are essential to balance the needs of both internal and external customers.
• The employee must be detail oriented, able to independently organize multiple tasks and priorities, and to effectively manage an assigned caseload under pressure of deadlines.
• Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) and Vaya information system is required.

LOCATION REQUIREMENT:

In accordance with the BH and I/DD Tailored Plan requirements mandated by the NC Department of Health and Human Services, certain Vaya Health positions are required to be filled by individuals who reside in North Carolina, meaning someone who establishes a legal domicile in North Carolina and pays income tax in North Carolina, or resides within 40 miles of the North Carolina border. New hires from outside of North Carolina will have 60 days from the date of hire to meet this requirement, if applicable to the position.

This position is required to reside in North Carolina or within 40 miles of the North Carolina Boarder.

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit http://www.vayahealth.com/careers-overview/ Ind.001