Prior Authorization Medical Clinician

WellSense Health Plan; New Hampshire; Remote; USD 49,000 - 71,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

403(b) match

Paid time off

Flexible Spending Accounts

Job summary

WellSense Health Plan is seeking a Prior Authorization Clinician to review proposed hospitalization, home care, and inpatient/outpatient services for medical necessity and efficiency to ensure timely, appropriate care for members.

The role requires RN licensure in NH or a compact state, 2+ years of prior authorization experience with InterQual guidelines, and managed care knowledge. This is a fully remote position with potential travel to the Charlestown, MA office for meetings.

Qualifications

• 2+ years prior authorization experience with InterQual guidelines.
• Managed care knowledge.

Responsibilities

• Determines medical appropriateness of inpatient and outpatient services following evaluation of guidelines.
• Performs utilization review activities including pre-certification, concurrent and retrospective reviews.
• Determines medical necessity by applying criteria to first level reviews and using approved guidelines.
• Communicates review outcomes and inquiries to providers and members.
• Refers cases to Physician Reviewer when not meeting medical necessity or when guidelines are unavailable.
• Sends system-generated letters to provider and member.
• Guides and coaches other utilization review nurses.
• Documents rate negotiation for proper claims adjudication.
• Identifies opportunities for improved communication or processes.
• Maintains compliance with Federal, State and accreditation organizations.

Skills

Prior authorization experience

InterQual guidelines

Managed care knowledge

Remote work capability

Education

RN license NH or compact state (NH)

Tools

Microsoft Office

Job description

WellSense Health Plan is a nonprofit health insurance company serving more than 680,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded more than 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances.

It’s an exciting time to join the 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.

Job Summary:

The Prior Authorization Clinician is responsible for reviewing all proposed hospitalization, home care, and inpatient/outpatient services for medical necessity and efficiency to ensure members receive the appropriate and timely care to support members in achieving optimal health outcomes.

Our Investment in You:

Key Functions/Responsibilities:

Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines applying evidenced-based InterQual® criteria, Medical Policy and benefit determination.

Performs utilization review activities, including pre-certification, concurrent and retrospective reviews according to guidelines.

Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines / criteria

Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.

Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all inquiries made and received regarding case communication.

Refers cases to Physician Reviewer when the treatment request does not meet medical necessity per guidelines, or when guidelines are not available.

Referrals must be made in a timely manner, allowing the Physician Reviewer time to make appropriate contact with the requesting provider in accordance with departmental policy and within each Medicaid, ACA, CMS or NCQA mandated turnaround times (TAT).

Demonstrates strong interpersonal and communication skills when conducting reviews, interacting with physicians and staff, and ensures compliance with training on related policies and procedures.

Sends appropriate system-generated letters to provider and member

Provides guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses

Follows all departmental policies and workflows in end-to-end management of cases.

Participates in team meetings, education, discussions, and related activities

Maintains compliance with Federal, State and accreditation organizations.

Identifies opportunities for improved communication or processes

May participate in audit activities and meetings

Documents rate negotiation accurately for proper claims adjudication

Identify and refer potential cases to Care Management

Performs all other related duties as assigned

Qualifications:

Education:

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 TelecommuterPolicy

Licensure, Certification or Conditions of Employment:

Active RN License in the state of NH, or a compact eligible state that includes NH

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

This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (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.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

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