Prior Authorization Medical Clinician

3+ years

Not Disclosed

Remote, USA

10 Dec. 5, 2024

Job Description

Job Type: Full Time Remote Education: BSN/ Life sciences Skills: Causality Assessment, Clinical SAS Programming, Communication Skills, CPC Certified, GCP guidelines, ICD-10 CM Codes, CPT-Codes, HCPCS Codes, ICD-10 CM, CPT, HCPCS Coding, ICH guidelines, ICSR Case Processing, Interpersonal Skill, Labelling Assessment, MedDRA Coding, Medical Billing, Medical Coding, Medical Terminology, Narrative Writing, Research & Development, Technical Skill, Triage of ICSRs, WHO DD Coding

Prior Authorization Medical Clinician

Location: Remote (United States)

About WellSense Health Plan:
WellSense Health Plan is a nonprofit health insurance organization serving over 740,000 members in Massachusetts and New Hampshire through Medicaid, Medicare, and Individual & Family plans. With 25+ years of experience, we are dedicated to providing inclusive, high-quality healthcare solutions tailored to our members' diverse needs.

Job Summary:

The Prior Authorization Medical Clinician evaluates and approves service requests based on organizational policies and InterQual® screening criteria. The role involves managing cases requiring medical necessity review, including home care, elective inpatient, and outpatient service requests, while adhering to state, federal, and regulatory requirements.

Key Responsibilities

Case Evaluation & Approval:
- Review cases referred by non-clinical staff, ensuring adherence to member benefits and medical necessity criteria.
- Advocate for appropriate utilization of healthcare resources, including site of service, level of care, and length of stay.
Documentation & Compliance:
- Maintain clear, accurate documentation in the UM system.
- Ensure compliance with regulatory standards and benefit designs for Massachusetts and New Hampshire products.
Collaboration & Communication:
- Identify members needing care management and coordinate with care managers.
- Collaborate with internal teams and build relationships with providers, facilities, and vendors to support program goals.
Problem Solving & Innovation:
- Utilize critical thinking to address workflow issues and implement solutions.
- Identify new approaches to improve member outcomes, stakeholder satisfaction, and departmental efficiency.
Productivity & Reporting:
- Manage caseloads efficiently to meet turnaround times and productivity standards.
- Represent the UM department in meetings as a subject matter expert when needed.

Qualifications

Education:

Bachelor’s Degree in Nursing or equivalent nursing degree with relevant experience.

Experience Required:

3+ years in acute care or health insurance environments.
2+ years in pre-authorization, utilization review, care coordination, or discharge planning.

Experience Preferred:

Acute care and/or rehabilitation nursing experience.
Experience working with Medicaid or Medicare populations.
Familiarity with FACETS, CCMS, InterQual®, ZeOmega’s Jiva, or similar healthcare databases.

Licensure & Certification:

Active, unrestricted RN license (required).
CCM Certification (preferred).

Skills & Competencies

Core Skills:
- Strong analytical, clinical problem-solving, and organizational abilities.
- Proficiency in Microsoft Office applications and healthcare databases.
Communication & Leadership:
- Excellent oral and written communication skills.
- Ability to foster positive dynamics within teams and adapt to change.
Work Environment:
- Ability to multitask in a fast-paced setting while maintaining accuracy and quality.
Preferred Competency:
- Bilingual skills are an asset.

Why Join WellSense?

Remote Flexibility: Full-time remote work available.
Competitive Benefits: Comprehensive salary and benefits package.
Inclusive Culture: Committed to diversity and inclusion in both staffing and member services.

Equal Opportunity Employer:
WellSense values diversity and is committed to equal employment opportunities. Qualified applicants are considered without regard to race, gender, disability, or veteran status.

Apply Today:
Be a part of a team that makes a meaningful impact on healthcare outcomes. Visit WellSense Careers to apply.

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Prior Authorization Medical Clinician

Job Description

Prior Authorization Medical Clinician

Job Summary:

Key Responsibilities

Qualifications

Education:

Experience Required:

Experience Preferred:

Licensure & Certification:

Skills & Competencies

Why Join WellSense?

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