Commonwealth Care Alliance
RN Utilization Management Reviewer
PayCompetitive
LocationBoston/Massachusetts
Employment typeFull-Time
This job is now closed
Job Description
- Req#: 5001068207406
- 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
- Additional duties as requested by supervisor
- Maintains knowledge of CMS, State and NCQA regulatory requirements
- Standard office conditions. Weekend work required on a rotational basis; some travel to home office may be required.
- Associate's Degree
- Bachelor's Degree
- RN
- CCM (Certified Case Manager)
- Yes, this is required if the incumbent is licensed in Massachusetts.
- 2 years Utilization Management experience.
- 2 or more years working in a clinical setting
- 2 or more years of Home Health Care experience
- 2 or more years working in a Medicare Advantage health Plan
- Ability to complete assigned work in a timely and accurate manner
- Knowledge of the Utilization management process
- Ability to work independently
- English
- 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
- Comfort working in a team-based environment
- Knowledge of Medicare and Mass health services and benefits
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 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
Essential Duties & Responsibilities:Working Conditions:What We're Looking For
Required Education (must have):Desired Education (nice to have):Required Licensing (must have):Desired Licensing (nice to have):MA Health Enrollment (required if licensed in Massachusetts):Required Experience (must have):Desired Experience (nice to have):Required Knowledge, Skills & Abilities (must have):Required Language (must have):Desired Knowledge, Skills, Abilities & Language (nice to have):Actual Work Location
Remote, Boston, Massachusetts 02108
All Locations
Remote - Boston
Exempt / Not Exempt
Exempt
About the company
Based in Massachusetts, Commonwealth Care Alliance (CCA) is a not-for-profit, community-based healthcare organization dedicated to improving care for individuals who are dually eligible for MassHealth (Medicaid) and Medicare with complex medical, behavioral health and social needs, including persons with disabilities. CCA offers two health plans: Senior Care Options (HMO SNP), for individuals ages 65 and over who have Medicare and MassHealth Standard or only MassHealth Standard; and One Care, a Massachusetts demonstration program for dual eligible individuals ages 21 to 64. These comprehensive health plans provide all the services covered under Medicare and MassHealth, and other benefits as determined necessary by an inter-professional care team in conjunction with CCA’s preferred provider network. For four consecutive years, CCA’s One Care plan received a top consumer rating for quality and access in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) national survey of Medicare-Medicaid Plans (2016, 2017, 2018, and 2019), administered by the Centers for Medicare & Medicaid (CMS).