Utilization Management Nurse Reviewer at Commonwealth Care Alliance in Springfield, Massachusetts

Job Description:

Utilization Management Nurse Reviewer

Job ID

2020-3537

Category

Clinical (Office Based)

Type

Regular Full-Time

Actual Work Location

101 Wason, Springfield, MA

Why This Role is Important to Us

At CCA, your role matters. You'll be joining an organization that is mission driven, believes in internal mobility, has excellent benefits and embraces innovation when it comes to serving our patients.

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.The Utilization Management Reviewer reports to the Utilization Management Manager.

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

What We're Looking For

- Associate's Degree in Nursing
- Bachelor of Science in Nursing, Physical Therapy, Occupational Therapy or related degree preferred
- 3+ years combined clinical and utilization management experience
- 3+ years experience working in a health plan preferred
- Ability to apply predetermined criteria (e.g., Interqual) to service decision requests to assess medical necessity
- Flexibility and understanding of individualized care plans
- Ability to influence decision making
- Strong interpersonal, verbal and written communication skills
- Ability to work independently
- Comfort working in a team based environment
- Will be required to pass CCA's credentialing process.
- English required, bilingual preferred

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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.