Massachusetts Healthcare Jobs

Why This Role is Important to Us:

Commonwealth Care Alliance’s (CCA) Clinical Effectiveness (Authorization) Unit is primarily responsible for the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of CCA’s benefits plan.

The Nurse Utilization Management (UM) Reviewer is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role in ensuring CCA meets CMS compliance standards in the area of service decisions and organizational determinations.

What You'll Be Doing:

• Conducts timely clinical decision review for services requiring prior authorization in a variety of clinical areas, including but not limited to surgical procedures, Medicare Part B medications, Long Term Services and Supports (LTSS), and Home Health (HH)

• Applies established criteria (e.g., Interqual and other available guidelines) and employs clinical expertise to interpret clinical criteria to determine medical necessity of services

• Communicates results of reviews verbally, in the medical record, and through official written notification to the primary care team, specialty providers, vendors and members in adherence with regulatory and contractual requirements

• Provides decision-making guidance to clinical teams on service planning as needed

• Works closely with CCA Clinicians, Medical Staff and Peer Reviewers to facilitate escalated reviews in accordance with Standard Operating Procedures

• Ensures accurate documentation of clinical decisions and works with UM Manager to ensure consistency in applying policy

• Works with UM Manager and other clinical leadership to ensure that departmental and organizational policies and procedures as well as regulatory and contractual requirements are met

• Creates and maintains database of denied service requests Additional duties as requested by supervisor

Working Conditions:

• Standard office conditions.

• Weekend work required on a rotational basis.

• Some travel to home office may be required.

What We're Looking For:

Education Desired:

• RN Associates Degree

Licensing Required:

• In the state applicable to the member's services, LPN with Certificate and active nursing license in good standing.

Experience Required:

• 3+ years

• 3+ years combined clinical and utilization management experience

• 3+ years' experience working in a health plan preferred

Knowledge, Skills & Abilities Required:

• Ability to apply predetermined criteria (e.g., Medical Necessity Guidelines, InterQual) to service decision requests to assess medical necessity

• Flexibility and understanding of individualized care plans

• Ability to influence decision making

• Strong collaboration and negotiation skills

• Strong interpersonal, verbal and written communication skills

• Ability to work independently

• Comfort working in a team-based environment

Language(s) Required:

• English required

Language(s) Desired:

• Bilingual preferred

Other Required:

• Standard office equipment

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job

• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

• While performing the duties of this job, the employee is regularly required to stand; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear

• The employee is occasionally required to walk; sit; and stoop, kneel, crouch, or crawl

• The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move more than 100 pounds

• Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus

Other Desired:

• Experience with utilization management platform preferred

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.