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Prior Authorization Medical Clinician

3+ years
Not Disclosed
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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