Utilization Reviewer for CES Waiver Services

Empower Healthcare Solutions, LLC.; Arkansas; Sur place; USD 55 000 - 70 000; Plein temps

Résumé du poste

Empower Healthcare Solutions, LLC. in Arkansas seeks a detail-driven Utilization Reviewer for CES Waiver Services to support utilization management for Medicaid members. You will collaborate with providers and internal teams to ensure timely, clinically appropriate care.

The role focuses on medical necessity reviews, accurate documentation, and alignment with regulatory standards, with opportunities to contribute to program improvements and care coordination.

Qualifications

• Experience with CES Waiver or similar Medicaid programs.
• Understanding of managed care and Arkansas Medicaid services.
• Excellent written and verbal communication skills.

Responsabilités

• Perform prior authorization reviews for CES Waiver services.
• Communicate with providers to gather clinical information for authorization.
• Determine medical necessity using established criteria.
• Review documentation for consistency with criteria and escalate when needed.
• Identify quality concerns and escalate to Quality Improvement teams.
• Maintain thorough documentation in relevant systems and SLAs.
• Compile and present cases in staffing and integrated rounds.
• Support continuous improvement of utilization management operations.

Connaissances

Communication

Critical thinking

Independent work

Team collaboration

Formation

High School Diploma

Description du poste

# Utilization Reviewer for CES Waiver Services## OverviewSalary Range$1.00 - $1.00 Salary/yearLevelExperiencedPosition TypeFull TimeJob ShiftDayEducation LevelNot SpecifiedTravel PercentageNegligibleCategoryHealth Care## DescriptionEmpower, a Provider-Led Arkansas Shared Savings Entity (PASSE) serving Medicaid clients with complex behavioral health and developmental disabilities, is seeking compassionate and detail-driven **Utilization Reviewer** **for CES Waiver Services** to support the utilization management process for our members utilizing those services. This role requires collaboration with providers and internal teams to ensure timely, clinically appropriate care while aligning with regulatory and organizational standards.**Key Responsibilities:*** Performs prior authorization reviews related to CES Wavier services such as: + Annual Supportive Living plans + Environmental Modifications + Adaptive Equipment* Communicate effectively with providers to gather additional clinical information and ensure smooth coordination of care.* Determine medical necessity using various criteria to ensure members receive the most appropriate level of care.* Review documentation for consistency with established criteria and escalate cases to Medical Directors when they do not meet medical necessity guidelines.* Identify potential quality-of-care concerns and escalate appropriately to the Quality Improvement team.* Maintain thorough and timely documentation in relevant systems to maintain all service level agreements (SLAs)* Compiles and presents cases in staffing and integrated rounds.* Collaborate with peers and leadership to support the continuous improvement of utilization management operations.## Qualifications* **Required:** At least 2 years of experience working with CES Waiver as a DSP supervisor or overseeing care plans.* Minimum: High School Diploma. Preferred: Some College* Understanding of managed care.* Familiarity with Medicaid services in Arkansas.* Excellent communication and critical thinking skills.* Ability to work independently while contributing to a collaborative team environment.