Prior Authorization Coordinator

This is a fully remote position, open to applicants in Connecticut.

📋 Description

• Collaborate effectively with Health Services personnel to carry out medical necessity review activities for members of the Community Health Network.

• Evaluate and determine the approval or denial of services based on the benefit package and medical necessity standards.

• Address telephonic and written requests for authorization and benefit coverage from CHNCT providers.

• Perform medical necessity evaluations for durable medical equipment (DME), outpatient therapies, and both inpatient and outpatient procedures.

• Recognize the need for coordination of benefits and third-party liability.

• Apply InterQual and/or Medicaid criteria to inform decision-making.

• Choose, format, proofread, and print denial letters for members and providers.

• Refer cases to the CHNCT Medical Reviewer when clinical information does not substantiate medical necessity.

• Aid in educating providers about CHNCT policies and procedures.

• Keep abreast of covered Medicaid benefits and convey information to clinical staff.

• Identify and refer cases for Intensive Care Management assessment.

• Elevate authorization issues to the Manager for resolution.

• Review requests for non-par and non-covered services and approve or deny them in accordance with established guidelines and policies.

• Execute additional responsibilities as assigned.

⛳️ Requirements

• Completion of two years of post-secondary education.

• Possession of an Associate's degree.

• Major in Licensed Practical Nursing.

• 3 to 5 years of relevant experience.

• Current Licensed Practical Nurse License.

• Familiarity with covered benefits for Medicaid programs.

• Competence in using InterQual and/or Medicaid criteria for decision-making.

• Capability to conduct medical necessity reviews and assess benefit coverage.

• Proficiency in reviewing authorization requests for DME, outpatient therapy, and inpatient and outpatient procedures.

🏝️ Benefits

• Options for medical, dental, and vision coverage.

• Flexible spending and health savings accounts available.

• Group term life insurance provided.

• A 401(k) plan with company matching and immediate vesting.

• Voluntary accidental injury insurance offered.

• Tuition reimbursement and opportunities for continuing education.

• A generous paid leave bank alongside company holidays.

• Wellness programs available.

• An inclusive and accessible interview process with reasonable accommodations offered.