Temporary LTSS Service Authorization Specialist

Why This Role is Important to Us:

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 LTSS Service Authorization Specialist is responsible for applying clinical and benefit administration policy guidelines to requests for authorizations for Long Term Services and Supports (LTSS). The LTSS Service Authorization Specialist provides accurate, prompt, and appropriate medical authorizations to requests from CCA Clinicians, Vendors and Providers for LTSS. The LTSS Service Authorization Specialist reports to the LTSS Service Authorization Team Lead.

What You'll Be Doing:

• Conducts decision review for services requiring prior authorization in LTSS leveraging technology and guidelines as available.

• Applies clinical and benefit administration policy guidelines to requests for authorizations

• Communicates results of reviews in the centralized enrollee record for the primary care team and clinical reviewers.

• Works closely with Team Lead to facilitate escalated reviews in accordance to Standard Operating Procedures.

• Assures accurate documentation of clinical decision and works with Team Lead to ensure consistency in applying policy.

• Determines the need for additional structured clinical data for completion of service decision request.

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

• Follows department and organizational policies and procedures as well as adheres to all applicable regulatory, contractual and compliance requirements.

• Fulfills duties as above within service standard turnaround times.

What We're Looking For:

• Associate's Degree or equivalent experience

• Bachelor's Degree

• 2+ years professional work experience in health care, managed care, or community-based service delivery.

• Experience in LTSS strongly preferred

• Training as a Behavioral Health Specialist, Social Worker or other related field preferred

• Familiarity with LTSS

• Knowledge of CPT and ICD coding preferred

• Flexibility and understanding of individualized care plans

• Strong interpersonal, verbal and written communication skills preferred

• Ability to work independently and make decisions

• Comfort working in a team based environment

• Working knowledge of and ability to navigate through the healthcare system and community based providers

• English required, bilingual preferred

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.