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013650 CCA-Auth & Utilization Mgmt
Position Summary Commonwealth Care Alliance's (CCA) Clinical Effectiveness (Authorization) Unit is primarily responsible for the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of CCA's benefits plan. The Service Authorization Specialist is responsible for providing accurate, prompt, and appropriate entry of all medical referrals and requests from CCA Clinicians, Members, Vendors and Providers for services needing prior authorization. The Service Authorizations Specialist reports to the Service Authorization Intake Manager. Supervision Exercised: No Essential Duties & Responsibilities
Coordinates with the clinical teams to conduct non-clinical activities required for medical management (e.g. ensuring submissions for completeness and accuracy, data entering required information, submitting service requests for clinical review). Assists with the accurate collection of necessary structured data for completion of service decision request. Provides clear and accurate documentation of all communication and activities. Handles all requests timely and accurately, adhering to performance measures. Additional duties as requested by supervisor.
Working Conditions Standard office conditions. Required Education Associate's Degree or equivalent experience Desired Education Bachelor's Degree Required Experience 1-3 years Desired Experience
Education, training or experience as a medical coder, medical billing, Insurance Coordinator or other relevant clinical background preferred Experience with care management platform preferred
Required Knowledge, Skills & Abilities
Medical terminology knowledge necessary. Basic arithmetic skills required. Working knowledge of CPT and ICD coding. Demonstrated ability of critical thinking skills to efficiently organize work and maintain a high level of accuracy and productivity. Working knowledge and ability to navigate through the healthcare system (insurances, Medicare, Medicaid, physician office operations). Ability to work independently with minimal supervision; as well as ability to work well in a team model to solve problems, improve workflow, and maintain cooperative working relationships with stakeholders. Proficiency in Microsoft Office Suite. Strong customer service and problem solving skills. Computer proficiency.
Required Language(s) English required Desired Language(s) bilingual preferred Physical Requirements:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions While performing the duties of this job, the employee is regularly required to stand; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear The employee is occasionally required to walk; sit; and stoop, kneel, crouch, or crawl The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move more than 100 pounds Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus
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Commonwealth Care Alliance
May 20, 2025