Utilization Management Reviewer

Position Summary:
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 Utilization Management (UM) Reviewer is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making. The 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:
* The Utilization Management Reviewer reports to the Utilization Management Manager.
* Conducts timely clinical decision review for services requiring prior authorization in a variety of clinical areas, including but not limited to Durable Medical Equipment/Services, 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. Some travel to clinical practices may be required.

Other:

Physical Requirements:

* 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

Required Education (must have):
* Associate degree

Required Experience (must have):
* 3+ years combined clinical and utilization management experience

Desired Experience (nice to have):
* 3+ years' experience working in a health plan preferred
* Experience with care management platform preferred

Required Knowledge, Skills & Abilities (must have):
* Ability to apply predetermined criteria (e.g., InterQual) to service decision requests to assess medical necessity
* Flexibility and understanding of individualized care plans
* Ability to influence decision making
* Strong interpersonal, verbal and written communication skills
* Ability to work independently
* Comfort working in a team-based environment
* Will be required to pass CCA's credentialing process.

Required Language (must have):
* English

Desired Knowledge, Skills, Abilities & Language (nice to have):
* bilingual preferred