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LTSS Coordinator at BMC HealthNet Plan in Boston, Massachusetts

Posted in Other 30+ days ago.

Job Description:

LTSS Coordinator


Acting as a liaison between Utilization Management, Care Management and Claims, the Long Term Support and Services (LTSS) Coordinator provides support to the cross-functional Senior Care Options (SCO) and NH Medicare Advantage product team by coordinating clinical and non-clinical data management to ensure delivery of timely and appropriate services to our members.

Key Functions/Responsibilities:

  • Monitors SCO fax queue and worklists and prioritizes and triage SCO Prior Authorization and LTSS requests.

  • Completes LTSS Utilization Management (UM) notification assessments in clinical care management documentation system and builds prior authorization

  • Reviews and builds episodes for Continuation of Care (COC) services of newly enrolled SCO members, ensuring timely data entry of authorized services into the clinical care management documentation system

  • Authorizes certain specified services, under the supervision of the UM Supervisor, according to departmental guidelines

  • Requests additional clinical information for service requests as needed.

  • Per standard workflows, forwards authorization requests that require clinical judgment to SCO UM Clinician, WellSense Medicare Advantage UM Clinician, or Supervisor, in a timely manner for review and processing

  • Assists in completing SCO member and provider notification letters within mandated timeframes and established quality parameters

  • Reviews and reconciles service events with unmatched claims in collaboration with care management and the claims

  • Serves as the liaison among SCO UM, CM, and Claims, ensuring there are no gaps in appropriate and necessary care to the SCO membership

  • Reaches out to service providers to ensure LTSS authorized services have been rendered to the SCO member, documenting in the clinical care management documentation

  • Monitors the UM SCO internal mailbox and follows through on service requests for SCO members; inquiries may be received from the following departments: PA, SCO Customer Care, Pharmacy, Contracting, Care Management, Claims,

  • Serves as point of contact for DME, medications, LTSS service authorizations for the SCO program, collaborating with CM, PA, Pharmacy, Vendor Management, Claims, and Customer

  • Adheres to policies and procedures in order to meet performance and compliance standards and to ensure cost effective and appropriate healthcare delivery.

  • Meets or exceeds position metrics andTurn-AroundTimeframes

  • Supports SCO UM Clinician, Wellsense Medicare Advantage UM Clinician as needed.

  • Identifies opportunities for workflow and process improvements related to the LTSS review and authorization

  • Other duties as assigned



  • Associate's degree in a Healthcare related field or equivalent combination of education and relevant work experience

Experience Required:

  • At least 2 years of office experience, specifically in either a high volume data entry office, customer service call center, or health care office administration department

  • 2 or more years of healthcare experience

  • Experience with health plan utilization/claims in a provider or payer

  • Prior customer service experience

  • Computer work experience that required active use of 2 or more software programs

Experience Preferred/Desirable:

  • Prior health plan experience

  • Experience with FACETS or clinical care management documentation systems or other, electronic medical records, other healthcare databases

  • Experience with Medicaid/SCO population and LTSS

  • Bilingual skills, fluency in Spanish

Competencies, Skills, and Attributes:

  • Ability to use healthcare clinical systems for documentation purposes; ability to effectively navigate systems

  • Excellent customer service and diplomacy skills

  • Ability to successfully collaborate across various functional departments and external constituents such as medical and other service providers

  • Ability to process a high volume of requests with a 95% or greater accuracy rate

  • Process improvement skills

  • Strong oral and written communication skills

  • A strong working knowledge of Microsoft Office products, including Excel

  • Ability to successfully organize and manage projects

  • Detail oriented

Working Conditions and Physical Effort:

  • Work is normally performed in a remote work environment

*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.

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