Rn Utilization Management Reviewer

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.

• 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
• Applies established criteria (e.g., Interqual and other available guidelines) and employs clinical expertise to interpret clinical criteria to determine medical necessity of services
• Creates and maintains database of denied service requests Additional duties as requested by supervisor
• Works closely with CCA Clinicians, Medical Staff and Peer Reviewers to facilitate escalated reviews in accordance with Standard Operating Procedures
• 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
• 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)
• Ensures accurate documentation of clinical decisions and works with UM Manager to ensure consistency in applying policy

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

• Ability to apply predetermined criteria (e.g., Medical Necessity Guidelines, InterQual) to service decision requests to assess medical necessity