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013650 CCA-Auth & Utilization Mgmt

Position Summary

Commonwealth Care Alliance’s (CCA) Clinical Effectiveness (Authorization) Unit is primarily responsible for the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of CCA’s benefits plan.

The Service Authorization Specialist is responsible for providing accurate, prompt, and appropriate entry of all medical referrals and requests from CCA Clinicians, Members, Vendors and Providers for services needing prior authorization.

The Service Authorizations Specialist reports to the Service Authorization Intake Manager.

Supervision Exercised: No

Essential Duties & Responsibilities

+ Coordinates with the clinical teams to conduct non‐clinical activities required for medical management (e.g. ensuring submissions for completeness and accuracy, data entering required information, submitting service requests for clinical review).

+ Assists with the accurate collection of necessary structured data for completion of service decision request.

+ Provides clear and accurate documentation of all communication and activities.

+ Handles all requests timely and accurately, adhering to performance measures.

+ Additional duties as requested by supervisor.

Working Conditions

Standard office conditions.

Required** **Education

Associate's Degree or equivalent experience

Desired Education

Bachelor's Degree

Required** **Experience

1-3 years

Desired** **Experience

+ Education, training or experience as a medical coder, medical billing, Insurance Coordinator or other relevant clinical background preferred

+ Experience with care management platform preferred

Required** **Knowledge, Skills & Abilities

+ Medical terminology knowledge necessary.

+ Basic arithmetic skills required.

+ Working knowledge of CPT and ICD coding.

+ Demonstrated ability of critical thinking skills to efficiently organize work and maintain a high level of accuracy and productivity.

+ Working knowledge and ability to navigate through the healthcare system (insurances, Medicare, Medicaid, physician office operations).

+ Ability to work independently with minimal supervision; as well as ability to work well in a team model to solve problems, improve workflow, and maintain cooperative working relationships with stakeholders.

+ Proficiency in Microsoft Office Suite.

+ Strong customer service and problem solving skills.

+ Computer proficiency.

Required** **Language(s)

English required

Desired** **Language(s)

bilingual preferred

Physical Requirements:

+ The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job

+ Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

+ While performing the duties of this job, the employee is regularly required to stand; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear

+ The employee is occasionally required to walk; sit; and stoop, kneel, crouch, or crawl

+ The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move more than 100 pounds

+ Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.