Utilization Management Nurse Reviewer - Boston, United States - Commonwealth Care Alliance
Description
Why This Role is Important to Us:
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.
The Utilization Management (UM) Reviewer is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making.
The 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:
Qualifications:
Associates Degree required
LPN with Certificate or active nursing license in good standing in the state of Massachusetts required
3+ years combined clinical and utilization management experience required
3+ years' experience working in a health plan preferred
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
English required,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).
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.