RN - Case Management Quality Reviewer
Glen Allen, Virginia
- 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).