Utilization Management Specialist at Commonwealth Care Alliance in Springfield, Massachusetts

Job Description:

Utilization Management Specialist

Job ID

2020-3538

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) Specialist is responsible for applying clinical and benefit administration policy guidelines to requests for authorizations. The UM Specialist provides accurate, prompt, and appropriate medical authorizations to requests from CCA Clinicians, Vendors and Providers.

This role is a 40 hour per week position with a varied schedule as needed, weekends included.

What You'll Be Doing

The UM Specialist reports to the Utilization Management Nurse Manager.
Uses established criteria to conduct preliminary decision review for services requiring prior authorization
- Applies clinical and benefit administration policy guidelines to requests for authorizations.
- Assesses the need for additional information to complete a service decision request.
- Enters authorizations into CCA's data system to ensure timely review of and downstream claims processing.
- Works closely with UM RN staff to escalate decisions that require clinical review and oversight.
- Communicates results of reviews in the centralized enrollee record for the primary care team and clinical reviewers.
- Handles all authorization requests timely and accurately, adhering to performance measures.
- Follows department and organizational policies and procedures as well as adheres to all applicable regulatory, contractual and compliance requirements.
- Fulfills duties as above within service standard turnaround times.

What We're Looking For

- Associate's Degree or equivalent experience
- Bachelor's Degree
- 2+ years professional work experience in health care, managed care, or insurance.
- Education, training or experience as a medical coder, medical billing, Insurance Coordinator or other relevant clinical background highly preferred
- Familiarity with utilization management review
- Knowledge of CPT and ICD coding highly preferred.
- Flexibility and understanding of individualized care plans.
- Excellent interpersonal, verbal and written communication skills.
- Ability to work independently and make decisions.
- Work in a team based environment.
- Working knowledge of and ability to navigate through the healthcare system (insurances, Medicare, Medicaid, physician office operations).
- English required, bilingual preferred.

Need help finding the right job?

We can recommend jobs specifically for you!
Click here to get started.

.

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.