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RN - Case Management Quality Reviewer

Glen Allen, Virginia

Job ID: 8505 Category: Health

Job Description

  • Our Program offers person-centered care planning, service coordination and self-supported care services for members receiving long-term care (LTC) and home and community (HCBS) services.
  • The LTSS Quality Reviewer (LQR) is responsible for performing field-based programmatic evaluation and contractual adherence to ensure LTSS Care/Case Manager/Coordinators are facilitating, promoting and advocating for the member’s ongoing self-sufficiency, independence and policy and procedure adherence. 
  • The LQR will conduct field-based ride along reviews in observance of LTSS CM/CC’s conducting face-to-face and/or telephonic assessments to assess the member’s need for supported self-care to alleviate functional deficits. 
  • The LQR conducts triangulation reviews to ensure congruency between the:

 

  • Plan of Care;

 

  • Authorizations; and,

 

  • Paid claims.

 

The LQR adheres to the Annual LTSS Quality Review Schedule.

LTSS Quality Reviewer Functions

  • Process completeness and contractual adherence of member visits;
  • Programmatic policy and procedural adherence; and,
  • Review clinical quality of face-to-face and telephonic assessments and interventions with members/care givers and appropriate associated documentation.
  • The focus is to identify the purpose/goal of interaction, use of motivational interviewing techniques in supporting member needs and in promoting CM driven/ member supported self-care at the most appropriate level of care, Plan of Care (POC).
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