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Job Details

Clinical Authorization Specialist

Category: Professional and Management
Commerce Place, Malden, MA

Department: Central Referral Dept
Job Type: Full Time
Job Class: Non-Union
Work Shift: Days
Work Days: Mon-Friday 6 hr days
Hours/Week: 30
Date Posted: 01/06/2020
Requisition Number: hrq-96205

Job Details

  • Performs prior authorization requests for various services that include but are not limited to sleep study, cardiology diagnostic testing or other specialty or high cost items such as advanced imagining. The role supports CHA primary care and specialty patients in ensuring there is administrative support and an administrative resource throughout the authorization process. Critical to this role is ensuring the test requested meets the insurance company's established parameters of ''medical appropriateness'' and ''medical necessity'' of care. In preparation to speak with insurance company, reviews provider request, pertinent clinical encounters, exams and tests using CHA medical record system(s) and EMR. The role serves as a liaison between the patient's healthcare team at CHA and the insurance company. Tasks include compiling, reviewing and assessing clinical notes and tests provided by the ordering provider to ensure they match specific clinical criteria or gu idelines set forth by the payors. Outreach to ordering providers via email or phone call prior to calling payors with the clinical information that supports testing. Gathers medical information upon which to base a decision, appeals the decision by the insurance company, or educate providers on appropriate guidelines for a given service. Notify ordering physician or rendering service provider of the preauthorization determination decision and when peer to peer MD review is needed. Serves as a collaborative resource and conduit between the CRO, provider, insurance company, and patient, if necessary. Ensures problems are promptly addressed, documented and rectified, accurately and on time, with the proper follow-up and professional customer service.


    Thorough knowledge of a specialized or technical field such as clinical nursing knowledge in medical/surgery, advanced imaging, or chemotherapy plus the application of basic managed care theory. Clinical background as a nurse, physician, coder, or other advanced clinical discipline required. Prior experience with management of medical information, hospital information systems and other tools in patient care, particularly with Epic and Meditech systems. Two years of current clinical experience in ambulatory care environment is preferred. Personal flexibility to perform in an ever-changing work environment with frequent interruptions. Prior experience in researching and assessing information governed by third party payers that impact prior authorizations for many different services, particularly in the ambulatory or surgical day care environment. Ability to manage and prioritize cases based on insurance requirements and delivery of timely service to the patien t. Motivated and self directed with a high degree of professional accountability and ability to work autonomously. Prior experience in case management, utilization review, utilization management, concurrent review, prior authorization, pre certification and medical necessity requirements required.


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