Job description

• 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.
• Additional duties as requested by supervisor

• LPN with Certificate and active MA nursing license in good standing or RN Associates Degree. Bachelor of Science in Nursing 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., 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
• Ability to work independently
• Comfort working in a team-based environment
• Will be required to pass CCA's credentialing process
• English required, Bilingual preferred
• Experience with utilization management platform preferred

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