Utilization Reviewer for CES Waiver Services

Empower, 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.

• 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.