Case Manager I (Prior Authorization) - 1001424
Position Purpose: Review requests for contract specific prior authorization of services within a centralized unit
- Review provider request for contract specific prior authorization through fax or telephone with application of evidence based criteria to ensure medical necessity for services
- Act as clinical resource to unit referral specialist staff and make appropriate referrals
- Provide provider education as directed
- Data entry and inquiry using both claims and clinical system software for performance of the authorization review process with documentation into the appropriate systems
Education/Experience: At least two years clinical nursing experience. Utilization review, prior authorization, or managed care experience preferred.
Licenses/Certifications: Current RN, LPN or LVN license required. Utilization Management (CPUR) certification, Certified Case Manager (CCM), or equivalent preferred.
Job: Clinical & Nursing
Primary Location: USA-Massachusetts-Waltham
Organization: Health Plans