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Community Health Network of Connecticut, Inc.
Community Health Network of Connecticut, Inc.
501 – 1,000 Employees
ConsultingHealthcareInsurance
Community Health Network of Connecticut, Inc. is a not-for-profit health plan serving Connecticut through population health management and care coordination. Its work combines data analytics, member and provider engagement, and evidence-based care interventions to support people managing chronic conditions, navigating transitions of care, and facing social determinants of health. The organization also works with community partners to improve health outcomes, coordinate services, and help manage healthcare utilization and costs. Its 501–1,000-person team operates at the intersection of healthcare, insurance, and consulting, with hiring connected to these areas of expertise.
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Remote Prior Authorization Coordinator - Connecticut

Review Medicaid authorizations and medical necessity for Community Health Network of Connecticut members. Apply InterQual criteria and coordinate provider communications about coverage decisions and denials.

USUnited StatesCTConnecticut
$51,075 – $68,100 / year
RemoteFull-timeMiddleSeniorEnglish RequiredGeneral

Description

  • Collaborate with Health Services staff on medical necessity reviews for Community Health Network members
  • Approve or deny services using benefit packages and medical necessity guidelines
  • Handle telephone and written authorization and benefit coverage requests from CHNCT providers
  • Review authorization requests for durable medical equipment, outpatient therapies, and inpatient and outpatient procedures
  • Assess coordination-of-benefits requirements and third-party liability
  • Apply InterQual and Medicaid criteria when making authorization decisions
  • Prepare, format, proofread, and print denial letters for members and providers
  • Refer cases to the CHNCT Medical Reviewer when clinical documentation does not support medical necessity
  • Help providers understand CHNCT policies and procedures
  • Keep current with covered Medicaid benefits and communicate updates to clinical staff
  • Identify cases that may require Intensive Care Management evaluation and make referrals
  • Escalate authorization concerns to the Manager for resolution
  • Evaluate non-participating provider and non-covered service requests under applicable guidelines and policies
  • Complete additional assigned duties

Requirements

  • Completion of two years of post-secondary education
  • Associate degree
  • Major in practical nursing
  • Three to five years of related experience
  • Current Licensed Practical Nurse license
  • Working knowledge of covered benefits under Medicaid programs
  • Ability to apply InterQual and Medicaid criteria when making decisions
  • Ability to perform medical necessity reviews and determine benefit coverage
  • Ability to evaluate authorization requests for durable medical equipment, outpatient therapy, and inpatient and outpatient procedures

Benefits

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

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