• Job Description

  Req#: 25-793
  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:

  • Standard office conditions. Weekend work may be required on a rotational basis; some travel to home office may be required.

  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)

  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.

  Compensation Range/Target: $72,480 - $108,720

  Commonwealth Care Alliance takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

• 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).

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