Prior Authorization Coordinator

Job not on LinkedIn

🔥 5 minutes ago

🦌 Connecticut – Remote

🦌 Connecticut – Remote

💵 $51.1k - $68.1k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

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Community Health Network of Connecticut, Inc.

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1995

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

Community Health Network of Connecticut, Inc. is a not-for-profit health plan based in Connecticut that provides population health management and care coordination services. It uses integrated data analytics, member and provider engagement, and evidence-based interventions to manage chronic disease, utilization, transitions of care, and social determinants of health. CHNCT focuses on improving member outcomes, reducing healthcare costs, and strengthening community partnerships through person-centered services and outreach.

📋 Description

• Work collaboratively with Health Services’ staff in conducting medical necessity review activities for Community Health Network members • Approve or deny services based on benefit package and medical necessity criteria • Respond to telephonic and written authorization and benefit coverage requests from CHNCT providers • Conduct medical necessity reviews for DME, outpatient therapies, and inpatient and outpatient procedures • Identify coordination of benefits needs and third-party liability • Utilize InterQual and/or Medicaid criteria to make decisions • Select, format, proofread, and print member and provider denial letters • Refer cases to the CHNCT Medical Reviewer when clinical information does not support medical necessity • Assist in educating providers on CHNCT policies and procedures • Maintain knowledge of covered Medicaid benefits and share information with clinical staff • Identify and refer cases for Intensive Care Management evaluation • Escalate authorization issues to the Manager for resolution • Review non-par and non-covered service requests and approve or deny them according to guidelines and policies • Perform other duties as assigned

🎯 Requirements

• Two years post-secondary schooling • Associate's degree • Licensed practical nursing major • 3 to 5 years’ related experience • Active Licensed Practical Nurse License • Knowledge of covered benefits for Medicaid programs • Ability to use InterQual and/or Medicaid criteria to make decisions • Ability to conduct medical necessity reviews and determine benefit coverage • Ability to review DME, outpatient therapy, inpatient and outpatient procedure authorization requests

🏖️ Benefits

• Medical, dental and vision coverage options • Flexible spending and health savings accounts • Group term life insurance • A 401(k) plan with company-match and immediate vesting • Voluntary accidental injury coverage • Tuition reimbursement and continuing education opportunities • A generous paid-leave bank and company holidays • Wellness program • Inclusive and accessible interview process with reasonable accommodations available