Position Summary: 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
No, this position does not have direct reports.
Essential Duties & Responsibilities
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
Working Conditions
Standard office conditions. Weekend work may be required on a rotational basis; some travel to home office may be required.