Nurse Utilization Management Reviewer

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

25-591

Remote/Remotely/Tele/Telecommute/From home