Prior Authorization Medical Clinician

WellSense Health Plan is a nonprofit health insurance company serving more than 680,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded more than 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances.

The Prior Authorization Clinician is responsible for reviewing all proposed hospitalization, home care, and inpatient/outpatient services for medical necessity and efficiency to ensure members receive the appropriate and timely care to support members in achieving optimal health outcomes. Our Investment in You: Full-time remote work Competitive salaries Excellent benefits

Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines applying evidenced-based InterQual® criteria, Medical Policy and benefit determination. Performs utilization review activities, including pre-certification, concurrent and retrospective reviews according to guidelines. Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines / criteria Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all inquiries made and received regarding case communication. Refers cases to Physician Reviewer when the treatment request does not meet medical necessity per guidelines, or when guidelines are not available. Referrals must be made in a timely manner, allowing the Physician Reviewer time to make appropriate contact with the requesting provider in accordance with departmental policy and within each Medicaid, ACA, CMS or NCQA mandated turnaround times (TAT). Demonstrates strong interpersonal and communication skills when conducting reviews, interacting with physicians and staff, and ensures compliance with training on related policies and procedures. Sends appropriate system-generated letters to provider and member Provides guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses Follows all departmental policies and workflows in end-to-end management of cases. Participates in team meetings, education, discussions, and related activities Maintains compliance with Federal, State and accreditation organizations. Identifies opportunities for improved communication or processes May participate in audit activities and meetings Documents rate negotiation accurately for proper claims adjudication Identify and refer potential cases to Care Management Performs all other related duties as assigned