Utilization Manager Registered Nurse (RN) Reviewer - MA only!

013650 CCA-Auth & Utilization Mgmt

Position Summary :

Reporting to the Manager Utilization Management, 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.

Supervision Exercised :

• No, this position does not have direct reports.

Essential Duties & Responsibilities :

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),DME 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

Working Conditions :

Required Education (must have) :

Desired Education (nice to have) :

Required Licensing (must have) :

Desired Licensing (nice to have) :

Required Experience (must have) :

2 to 3 years Utilization Management experience in a managed care setting

2 or more years working in a clinical setting

Desired Experience (nice to have) :

2 or more years of Home Health Care experience

2 or more years of LTSS experience

2 or more years working in a Medicare Advantage health Plan

Required Knowledge, Skills & Abilities (must have) :

Experience with prior authorization and retrospective reviews

Proficiency reviewing clinical / medical records and determining medical necessity based on evidence-based guidelines, e.g. Inter Qual

Ability to complete assigned work in a timely and accurate manner

Knowledge of the Utilization management process, including understanding of CMS and state Medicaid regulations.

Ability to work independently

Desired Knowledge, Skills, Abilities & Language (nice to have) :

Flexibility and understanding of individualized care plans

Ability to influence decision making

Strong collaboration and negotiation skills

Strong interpersonal, verbal, and written communication skills

Strong organizational skills to manage multiple reviews and timelines efficiently

Comfort working in a team-based environment

This position is available to remote employees residing in Massachusetts. Applicants residing in other states will not be considered at this time.

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.