Prior Authorization Coordinator

Community Health Network of Connecticut•Wallingford, CT

6d•Onsite

About The Position

Community Health Network of Connecticut, Inc. (CHNCT) is currently seeking a Prior Authorization Coordinator to join our team. This role involves collaborating with Health Services’ staff in conducting medical necessity review activities for Community Health Network members, approving or denying services based on benefit package and medical necessity criteria. The coordinator will respond to telephonic and written requests for authorization and benefit coverage, conduct medical necessity reviews for various services, identify coordination of benefits and third-party liability, and utilize InterQual and/or Medicaid criteria for decision-making. Additionally, the role includes preparing and mailing denial letters, referring cases to a Medical Reviewer when necessary, and assisting in educating providers on CHNCT policies and procedures. Essential functions include maintaining knowledge of covered benefits, sharing information with clinical staff, identifying cases for Intensive Care Management, and resolving authorization issues with the Manager.

Requirements

Active Licensed Practical Nurse License

Nice To Haves

Two years post-secondary schooling
Associate's degree
Licensed practical nursing
3 to 5 years’ related experience

Responsibilities

Works collaboratively with Health Services’ staff in conducting medical necessity review activities for Community Health Network members.
Approves or denies services based on benefit package and medical necessity criteria.
Responds to telephonic and written requests by CHNCT providers for authorization and benefit coverage for CHNCT members.
Conducts medical necessity review of requests for DME, outpatient therapies and prior authorizations for inpatient and outpatient procedures.
Identifies need for coordination of benefits and identifies third party liability as appropriate.
Utilizes the InterQual and or Medicaid criteria to make decisions.
Selects, formats, proofreads and prints appropriate member and provider denial letters prior to mailing.
Refers cases to CHNCT Medical Reviewer when clinical information does not support medical necessity.
Assists in education of primary care providers, specialists and ancillary providers on CHNCT policies and procedures.
Performs other duties as assigned.
Maintains knowledge of covered benefits for Medicaid programs.
Shares information as necessary with appropriate clinical staff.
Identifies and refers cases appropriate for Intensive Care Management evaluation.
Identifies authorization issues and brings those requiring attention to the Manager for resolution.
Reviews requests for non-par services and approves or denies based on guidelines/policies.
Reviews requests for services not included in member’s benefit package.