Clinical - Program Specialist (Social Worker) 1

Location : This position is REMOTE , but does require travel to team meetings a few times per year to McAllen, TX.

SHIFT : M-F 8-5 possible OT if needed

Job Description : Summary : Conduct screening and risk assessment interventions per program guidelines. Assist with non medical aspects of the member's care, including referrals to community resources.

Job Responsibilities : Identify special needs members through the completion of health screens and other resources Work with community outreach / member advocates to coordinate member care Educate providers and community resources on program components and available support services Educate members with special needs to foster compliance with program and positively impact outcomes Conduct site visits as appropriate for programs and provide support to other special programs Develop and modify care plans in conjunction with member, member's family and managing physician Development of plan specific literature and education materials in conjunction with medical director and corporate oversightEducation / Experience : Bachelor's degree in Social Work, Nursing, Health, Behavioral Science or Equivalent Experience.

Experience in a managed care environment preferred. 0-2 years of experience Walk me through the day to day responsibilities of this the role and a description of the project :

• Telehealth assessments
• Review assessments & service plans (vendor or internal assessments)
• Follow up on pending assessment findings, clarify DX, reported abnormals, requested referrals, etc.
• Hospital discharges follow up
• 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
• MSC call backs.
• CDS review
• cute 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, hearing, 90 day MHM, 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.

Describe the performance expectations / metrics for this individual and their team :

Review monthly audits and weekly calls to ensure we are meeting contractual requirements.

Tell me about what their first day looks like :

Will call the employee to make sure they are signed in. They will complete new hire trainings.

What previous job titles or background work will in this role?

Service Coordinator

ny future projected positions potentially coming up? NO

Internal / External Groups with which the Candidate will interface : Required Skills / Experience : Preferred Skills / Experience : 1.

Excellent computer skills 1. Previous MCO experience 2. Proficient in Word, Excel, and PowerPoint 2. Spanish Speaking preferred 3.

3. Education Requirement : BA-Social work Education Preferred : Software Skills Required : Required Certifications : Required Testing :