Complex Population, Service Determination Specialist II

Job Summary: Complex Population Service Determination Specialist II is responsible for processing medical necessity and noncommunity supports and service health care reviews for appropriateness of authorization to include home and community-based supports. This role assists with discharge planning activities and care coordination for members enrolled with a CareSource Management Group line of business, as well as monitoring the delivery of healthcare services in a cost-effective manner. Essential Functions: Compares PCSP to service request submitted by provider to ensure accuracy and need for services Conducts front and back end reviews of services approved in Cite Auto Auth or by staff Works with provider network and Care Coordination to communicate and address provider concerns resulting from clinical quality audits and/or cite auto auth reviews Leads collaboration with Care Coordination on transition and discharge plans for members receiving highest levels of I/DD and BH treatment Responsible for the prior authorization of BH/SUD/IDD/HCBS/Waiver PASSE services. Responsible for retro-authorization requests and continued stay reviews Collaboration with Medical Directors and Care Coordinators to ensure the best service is in place Familiar with Evidence Based Care systems such as MCG, ASAM, HCBS waiver guidelines Maintain knowledge of state and federal regulations governing CareSource , state contracts, provider agreements, benefits, and NCQA standards Consistent application