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    Prior Authorization Medical Clinician

    Wellsense Health Plan
    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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