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Utilization Management Review Nurse

Company: Commonwealth Care Alliance
Location: Charlestown
Posted on: June 19, 2018

Job Description:


Utilization Management Review Nurse


Spanish Preferred


Commonwealth Care Alliance is a rapidly growing nonprofit organization providing integrated health care and social support services to people with complex medical needs. Our patients are seniors and persons with disabilities covered under Medicaid or 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.
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) REVIEW NURSE is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making. The Utilization Management Review Nurse has a key role in ensuring CCA meets CMS compliance standards in the area of service decisions and organizational determinations.


The Utilization Management Review Nurse reports to the Utilization Management Nurse Manager.
* 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)
* 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

Minimum Education Required Associate's Degree in Nursing
Preferred Educational Experience Bachelor of Science in Nursing or related degree preferred
Minimum Years Experience Required 3 years
Minimum Experience:
* 3 years combined clinical and utilization management experience
* 3 years experience working in a health plan preferred

* 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.

Working Conditions Office environment, some travel to clinical practices may be required.

Equipment Utilized
* Standard office equipment
* Experience with care management platform preferred

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable).

Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.

CCA is committed to protecting the health of our workforce and our members, and we encourage flu vaccination in accordance with CDC recommendations. Individuals working in clinical care areas or in direct contact with members must provide documentation of flu vaccination, or wear a mask during flu season whenever engaged in member-facing activities.

Keywords: Commonwealth Care Alliance, Attleboro, Utilization Management Review Nurse, Executive, Charlestown, Massachusetts

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