Care Management Oversight Specialist

Care Management Oversight Specialist

We are seeking a Care Management Oversight Specialist to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations.

The Care Management Oversight Specialist plays an essential role in promoting the delivery of high-quality, member-centered care through the review and evaluation of service requests for Long-Term Care (LTC) and Intellectual and Developmental Disabilities (IDD) members. This position works closely with care management and care coordination teams to review assessed member needs, clinical information, and requested services to ensure the appropriateness of care and alignment with applicable guidelines, policies, and program requirements. The Care Management Oversight Specialist collaborates closely with the Medical Director(s), who retain ultimate responsibility for final determinations regarding the medical necessity of requested services.

Minimum Qualifications:

• Bachelor's degree in Nursing, Healthcare Administration, Social Work, or a related field.
• Five (5) years of experience in care management, care coordination, or utilization management within LTC and IDD populations.
• Strong knowledge of healthcare regulations, medical necessity criteria, and care management principles.
• Experience reviewing service requests, assessing member needs, and applying clinical or program guidelines to support appropriate care decisions.
• Excellent verbal and written communication skills, with the ability to effectively collaborate with interdisciplinary teams, providers, leadership, and other stakeholders.
• Relevant experience may substitute for educational requirement on a year-for-year basis.

Preferred Qualifications:

• Master's degree in Nursing, Healthcare Administration, Social Work, Public Health, or a related field.
• Active and unrestricted professional license or certification, such as Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), or other relevant credential.
• Certification in Case Management (CCM) or Utilization Management.
• Experience using care management, utilization management, or electronic health record systems.
• Familiarity with evidence-based guidelines, utilization management criteria, and person-centered service planning.

Responsibilities:

• Demonstrate commitment to Our Mission and models ILS Experience Standards of Excellence.
• Complete service request reviews accurately and within all contractual, regulatory, and internal timeliness standards.
• Work closely with care managers to gather additional information regarding the member's care needs, as applicable.
• Refer cases to the Medical Director for final determination when the member's current situation and conditions do not justify the service request.
• Coordinate and facilitate ad-hoc Interdisciplinary Care Team (ICT) meetings to review complex cases that require a multidisciplinary approach.
• Identify trends recurring issues, and opportunities for improvement at the department, team, and individual levels related to care planning, service requests, and utilization patterns.
• Remain current on regulatory changes, benefit coverage, and program requirements affecting service review processes.
• Perform other duties as assigned.