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:

• 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

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:

Required Education (must have):

• Associate's Degree

Desired Education (nice to have):

• Bachelor's Degree

Required Licensing (must have):

• RN

Desired Licensing (nice to have):

• CCM (Certified Case Manager)

MA Health Enrollment (required if licensed in Massachusetts):

• Yes, this is required if the incumbent is licensed in Massachusetts.

Required Experience (must have):

• 1 to 2 years Utilization Management experience.

• 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 working in a Medicare Advantage health Plan

Required Knowledge, Skills & Abilities (must have):

• Ability to complete assigned work in a timely and accurate manner

• Knowledge of the Utilization management process

• Ability to work independently

Required Language (must have):

• English

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

• 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

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.