Prior Authorization Coordinator

Job Description:

• Work collaboratively with Health Services’ staff in conducting medical necessity review activities for Community Health Network members
• Approve or deny services based on benefit package and medical necessity criteria
• Respond to telephonic and written authorization and benefit coverage requests from CHNCT providers
• Conduct medical necessity reviews for DME, outpatient therapies, and inpatient and outpatient procedures
• Identify coordination of benefits needs and third-party liability
• Utilize InterQual and/or Medicaid criteria to make decisions
• Select, format, proofread, and print member and provider denial letters
• Refer cases to the CHNCT Medical Reviewer when clinical information does not support medical necessity
• Assist in educating providers on CHNCT policies and procedures
• Maintain knowledge of covered Medicaid benefits and share information with clinical staff
• Identify and refer cases for Intensive Care Management evaluation
• Escalate authorization issues to the Manager for resolution
• Review non-par and non-covered service requests and approve or deny them according to guidelines and policies
• Perform other duties as assigned

Requirements:

• Two years post-secondary schooling
• Associate's degree
• Licensed practical nursing major
• 3 to 5 years’ related experience
• Active Licensed Practical Nurse License
• Knowledge of covered benefits for Medicaid programs
• Ability to use InterQual and/or Medicaid criteria to make decisions
• Ability to conduct medical necessity reviews and determine benefit coverage
• Ability to review DME, outpatient therapy, inpatient and outpatient procedure authorization requests

Benefits:

• Medical, dental and vision coverage options
• Flexible spending and health savings accounts
• Group term life insurance
• A 401(k) plan with company-match and immediate vesting
• Voluntary accidental injury coverage
• Tuition reimbursement and continuing education opportunities
• A generous paid-leave bank and company holidays
• Wellness program
• Inclusive and accessible interview process with reasonable accommodations available