TC, Medical Social Work
Master's Level Degree
RN - Bachelor's Level Degree
3 years clinical experience required
3 years related experience required
Licensed Clinical Social Worker
Monday - Friday, 8am-5pm
Assumes responsibility, accountability and leadership for the daily operations including coordination of work, quality, and service. First line supervisor in the Utilization Management Department. Facilitates the work of assigned team members. Provides a leadership role in ongoing utilization review competency assessment, needs identification and educational offerings. Provides educational services to the Utilization Management staff. Participates in the work activities of assigned teams. Responsible for review of clinical information received from providers ensuring clinical data is substantial enough to meet Medical Necessity Criteria to authorize services as needed. Requires knowledge of managed care contracting, Medical Necessity, CMHRS services, DMAS protocols, clinical protocols and clinical review requirements. Requires knowledge of contractual, regulatory and compliance requirements for government payers, self funded and commercial payers. Ensures appropriate and accurate information is entered into claims system for processing of payment.
Optima Health Community Care is a Commonwealth Coordinated Care Plus (CCC Plus) Medicaid plan for many older people and those with disabilities. CCC Plus is a Medicaid managed care program through the Virginia Department of Medical Assistance Services (DMAS).
With Optima Health Community Care, members benefit from an individualized, fully-integrated program with a state-wide network of providers. As an Optima Health Community employee, you will join a care team committed to providing customized and personalized support and services in the community that our members can count on. Optima Health is a service of Sentara Healthcare, so joining Optima is joining the Sentara Healthcare family.
Sentara employees strive to make our communities healthier places to live. We're setting the standard for medical excellence within a vibrant, creative, and highly productive workplace. For more information about our employee benefits, CLICK HERE!
Join our team, where we are committed to quality healthcare, improving health every day, and provide the opportunity for training, development, growth! Other
BSN or Master's in Social Work required. 3 years experience working in either in patient or outpatient services dealing with authorizations and medical necessity criteria and 3 year experience working with vulnerable populations. Virginia RN license or LCSW required.