Job Description Evaluates and approves requested services using Organizational Policies or InterQual® screening criteria. Manages appropriate cases that may require single services such as Home and Outpatient Service Requests for Skilled Nursing, OT, PT, DME, and Elective Surgeries. Monitors and complies with all state and DOI requirements relative to accuracy and turn around time for PARS and adheres to the benefit design of MH and CWC in managing all requests.
Key Functions & Responsibilities:
- Reviews cases referred by the prior-authorization non-clinical staff according to member benefits, provider availability, and pre-determined medical necessity criteria.
- Determine the medical necessity of initial or continuing services using nationally approved criteria sets.
- Refers all cases that do not meet criteria to the BMCHP Medical Director for final determination.
- Identifies members who could benefit from care management according to the Care Management Referral Screen and refers to the appropriate care manager.
- Enters data accurately, timely, and completely; documents all encounters according to the department policies and workflows and complies with contractual requirements regarding turn-around-times.
- Maintains caseload volume and turn around times meeting department productivity standards.
- Provides high level of service and satisfaction to internal and external customers.
Education & Experience:
Required:
- Bachelors Degree in Nursing or Nursing School Degree with equivalent relevant work experience.
- 3 years related experience in an acute care or health insurance environment.
- 2 years experience with pre-authorization, utilization review/management, case management, care coordination, and/or discharge planning.
Preferred:
- CCM certification.
- Experience in acute care and/or rehab nursing.
- Experience with Medicaid recipients and community services.
- Experience with FACETS, CCMS, Interqual or other healthcare database.
- Current MA state licensure as a Registered Nurse.
- Bi-lingual.
Competencies, Skills, & Attributes:
- Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts.
- Demonstrated strong organization and time management skills.
- Able to work in a fast paced environment; ability to multi-task.
- Experience with standard Microsoft Office applications, particularly MS Outlook and MS Word, and other data entry processing applications.
- Strong analytical and clinical problem solving skills.
Job Location
Boston, MA, US.
Position Type
Full-Time/Regular
