Registered Nurse (RN) Utilization Management Reviewer

Commonwealth Care Alliance is a nonprofit organization based in Massachusetts that provides integrated health care and social support services to people with the most significant healthcare needs. Our members and patients are seniors and persons with disabilities covered by both Medicaid and Medicare. Our innovative care model is nationally recognized for its effectiveness in improving health outcomes for these vulnerable populations. Our unique care model is empowering for our employees as well as our members. Whether you are a clinical or administrative professional, all of us at Commonwealth Care Alliance receive the satisfaction of knowing our work truly makes a difference. We enjoy a company culture of passionate advocacy in a supportive work environment with opportunities for growth and learning, competitive salaries, and a generous and comprehensive benefit package.

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.

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