Commonwealth Care Alliance

Registered Nurse (RN) Utilization Nurse Reviewer for LTSS


PayCompetitive
LocationBoston/Massachusetts
Employment typeFull-Time

This job is now closed

  • Job Description

      Req#: 5001060367500

      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 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.

      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 Additional duties as requested by supervisor
      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

      Qualifications:
      • Associates Degree required, Bachelor's Degree preferred.
      • RN license in the state applicable to the member's services, active nursing license in good standing required.
      • CCM (Certified Case Manager) preferred
      • 1 to 2 years Utilization Management experience required.
      • 2 or more years working in a clinical setting required.
      • 2 or more years of Home Health Care experience preferred.
      • 2 or more years working in a Medicare Advantage health plan preferred.
      • Ability to complete assigned work in a timely and accurate manner required.
      • Knowledge of the Utilization management process required.
      • Ability to work independently required.
      Language(s) Required:
      • English required, Bilingual preferred
      Other Required:
      • Standard office equipment
      • The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job
      • Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
      • While performing the duties of this job, the employee is regularly required to stand; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear
      • The employee is occasionally required to walk; sit; and stoop, kneel, crouch, or crawl
      • The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move more than 100 pounds
      • Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus
      Other Desired:
      • Experience with utilization management platform preferred

      Actual Work Location

      Remote, Boston, Massachusetts 02108

      All Locations

      Remote - Boston

      Exempt / Not Exempt

      Exempt

  • About the company

      Based in Massachusetts, Commonwealth Care Alliance (CCA) is a not-for-profit, community-based healthcare organization dedicated to improving care for individuals who are dually eligible for MassHealth (Medicaid) and Medicare with complex medical, behavioral health and social needs, including persons with disabilities. CCA offers two health plans: Senior Care Options (HMO SNP), for individuals ages 65 and over who have Medicare and MassHealth Standard or only MassHealth Standard; and One Care, a Massachusetts demonstration program for dual eligible individuals ages 21 to 64. These comprehensive health plans provide all the services covered under Medicare and MassHealth, and other benefits as determined necessary by an inter-professional care team in conjunction with CCA’s preferred provider network. For four consecutive years, CCA’s One Care plan received a top consumer rating for quality and access in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) national survey of Medicare-Medicaid Plans (2016, 2017, 2018, and 2019), administered by the Centers for Medicare & Medicaid (CMS).