Job Description

Nurse Utilization Management Reviewer

Position Summary: Reporting to the Manager Utilization Management, the Nurse Utilization Management 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

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.

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