WellSense Health Plan
Prior Authorization Medical Clinician
WellSense Health Plan, Boston, Massachusetts, us, 02298
Prior Authorization Medical Clinician — WellSense Health Plan
A growing regional health insurance company with a 25‑year history of providing health insurance that works for our members, no matter their circumstances. Join us to support members in achieving optimal health outcomes.
Job Summary
The Prior Authorization Clinician reviews all proposed hospitalization, home care, and inpatient/outpatient services for medical necessity and efficiency to ensure members receive appropriate and timely care.
Our Investment In You
Full‑time remote work
Competitive salaries
Excellent benefits
Key Functions / Responsibilities
Determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines applying evidence‑based InterQual® criteria, Medical Policy, and benefit determination.
Perform utilization review activities, including pre‑certification, concurrent and retrospective reviews according to guidelines.
Determine medical necessity of each request by applying appropriate medical criteria to first‑level reviews and utilizing approved evidence‑based guidelines/criteria.
Utilize decision‑making and critical‑thinking skills in the review and determination of coverage for medically necessary health‑care services.
Review, document, and communicate all utilization‑review activities and outcomes, including inquiries made and received regarding case communication.
Refer cases to Physician Reviewer when the treatment request does not meet medical necessity per guidelines, or when guidelines are not available.
Make referrals in a timely manner, allowing the Physician Reviewer time to contact the requesting provider in accordance with departmental policy and within each Medicaid, ACA, CMS or NCQA mandated turnaround times (TAT).
Demonstrate strong interpersonal and communication skills when conducting reviews, interacting with physicians and staff, and ensure compliance with training on related policies and procedures.
Send appropriate system‑generated letters to provider and member.
Provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses.
Follow all departmental policies and workflows in end‑to‑end management of cases.
Participate in team meetings, education, discussions, and related activities.
Maintain compliance with Federal, State and accreditation organizations.
Identify opportunities for improved communication or processes.
May participate in audit activities and meetings.
Document rate negotiation accurately for proper claims adjudication.
Identify and refer potential cases to Care Management.
Perform all other related duties as assigned.
Qualifications
Education
Nursing degree or diploma required; bachelor’s degree in nursing preferred.
Preferred/Desirable
Bachelor’s degree.
RN license in state of MA, NH or compact license.
Medicare and Medicaid knowledge.
Experience
2+ years prior authorization experience and evidence‑based guidelines (InterQual Guidelines).
Managed care experience.
All employees working remotely will be required to adhere to WellSense’s Telecommuter Policy.
Licensure, Certification, or Conditions of Employment
Active, unrestricted RN license in state of residence.
Pre‑employment background check.
Ability to take after‑hours call, including evening/nights/weekends.
Competencies, Skills, and Attributes
Strong oral and written communication skills.
Strong clinical judgement and critical thinking skills to assess complex cases and determine appropriate levels of care.
Excellent communication and interpersonal skills to engage effectively with internal and external stakeholders.
Ability to work independently in a remote environment while maintaining adherence to timeliness and regulatory requirements.
Proficiency in Microsoft Office applications and data management systems.
Demonstrated organizational and time‑management skills.
Strong analytical and clinical problem‑solving abilities with focus on quality improvement initiatives.
Working Conditions and Physical Effort
Fully remote position with possible travel to the Charlestown, MA office for team meetings and training sessions.
Fast‑paced and dynamic work environment requiring adaptability and focus.
Minimal physical effort required; primarily desk‑based tasks such as documentation and virtual meetings.
Regular and reliable attendance is essential.
Compensation Range $35.58 – $51.44 per hour; includes generous benefits such as medical, dental, vision, pharmacy, merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.
Note:
This range is based on Boston‑area data and is subject to modification based on geographic location.
EEO Statement Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E‑Verify program to electronically verify the employment eligibility of newly hired employees.
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Job Summary
The Prior Authorization Clinician reviews all proposed hospitalization, home care, and inpatient/outpatient services for medical necessity and efficiency to ensure members receive appropriate and timely care.
Our Investment In You
Full‑time remote work
Competitive salaries
Excellent benefits
Key Functions / Responsibilities
Determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines applying evidence‑based InterQual® criteria, Medical Policy, and benefit determination.
Perform utilization review activities, including pre‑certification, concurrent and retrospective reviews according to guidelines.
Determine medical necessity of each request by applying appropriate medical criteria to first‑level reviews and utilizing approved evidence‑based guidelines/criteria.
Utilize decision‑making and critical‑thinking skills in the review and determination of coverage for medically necessary health‑care services.
Review, document, and communicate all utilization‑review activities and outcomes, including inquiries made and received regarding case communication.
Refer cases to Physician Reviewer when the treatment request does not meet medical necessity per guidelines, or when guidelines are not available.
Make referrals in a timely manner, allowing the Physician Reviewer time to contact the requesting provider in accordance with departmental policy and within each Medicaid, ACA, CMS or NCQA mandated turnaround times (TAT).
Demonstrate strong interpersonal and communication skills when conducting reviews, interacting with physicians and staff, and ensure compliance with training on related policies and procedures.
Send appropriate system‑generated letters to provider and member.
Provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses.
Follow all departmental policies and workflows in end‑to‑end management of cases.
Participate in team meetings, education, discussions, and related activities.
Maintain compliance with Federal, State and accreditation organizations.
Identify opportunities for improved communication or processes.
May participate in audit activities and meetings.
Document rate negotiation accurately for proper claims adjudication.
Identify and refer potential cases to Care Management.
Perform all other related duties as assigned.
Qualifications
Education
Nursing degree or diploma required; bachelor’s degree in nursing preferred.
Preferred/Desirable
Bachelor’s degree.
RN license in state of MA, NH or compact license.
Medicare and Medicaid knowledge.
Experience
2+ years prior authorization experience and evidence‑based guidelines (InterQual Guidelines).
Managed care experience.
All employees working remotely will be required to adhere to WellSense’s Telecommuter Policy.
Licensure, Certification, or Conditions of Employment
Active, unrestricted RN license in state of residence.
Pre‑employment background check.
Ability to take after‑hours call, including evening/nights/weekends.
Competencies, Skills, and Attributes
Strong oral and written communication skills.
Strong clinical judgement and critical thinking skills to assess complex cases and determine appropriate levels of care.
Excellent communication and interpersonal skills to engage effectively with internal and external stakeholders.
Ability to work independently in a remote environment while maintaining adherence to timeliness and regulatory requirements.
Proficiency in Microsoft Office applications and data management systems.
Demonstrated organizational and time‑management skills.
Strong analytical and clinical problem‑solving abilities with focus on quality improvement initiatives.
Working Conditions and Physical Effort
Fully remote position with possible travel to the Charlestown, MA office for team meetings and training sessions.
Fast‑paced and dynamic work environment requiring adaptability and focus.
Minimal physical effort required; primarily desk‑based tasks such as documentation and virtual meetings.
Regular and reliable attendance is essential.
Compensation Range $35.58 – $51.44 per hour; includes generous benefits such as medical, dental, vision, pharmacy, merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.
Note:
This range is based on Boston‑area data and is subject to modification based on geographic location.
EEO Statement Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E‑Verify program to electronically verify the employment eligibility of newly hired employees.
#J-18808-Ljbffr