Prior Authorization Coordinator

Job Description

Job Description

Community Health Network of Connecticut, Inc. (CHNCT) is currently seeking a Prior Authorization Coordinator (LPN).

Primary Responsibilities:

• Works collaboratively with Health Services’ staff in conducting medical necessity review
• activities for Community Health Network members.
• Approves or denies services based on benefit package and medical necessity criteria.

Tasks Performed:

• Responds to telephonic and written requests by CHNCT providers for authorization and benefit coverage for CHNCT members.
• Conducts medical necessity review of requests for DME, outpatient therapies and prior authorizations for inpatient and outpatient procedures.
• Identifies need for coordination of benefits and identifies third party liability as appropriate.
• Utilizes the InterQual and or Medicaid criteria to make decisions.
• Selects, formats, proofreads and prints appropriate member and provider denial letters prior to mailing.
• Refers cases to CHNCT Medical Reviewer when clinical information does not support medical necessity.
• Assists in education of primary care providers, specialists and ancillary providers on CHNCT policies and procedures.
• Performs other duties as assigned.

Essential Functions:

• Maintains knowledge of covered benefits for Medicaid programs.
• Shares information as necessary with appropriate clinical staff.
• Identifies and refers cases appropriate for Intensive Care Management evaluation.
• Identifies authorization issues and brings those requiring attention to the Manager for resolution.
• Reviews requests for non-par services and approves or denies based on guidelines/policies.
• Reviews requests for services not included in member’s benefit package.

Desired Education: Two years post-secondary schooling

Desired Degree: Associate's degree

Desired Major: Licensed practical nursing

Desired Job Experience: 3 to 5 years related experience

Certifications Required: Active Licensed Practical Nurse License

We are dedicated to having a workplace where everyone feels valued, respected, and empowered to succeed. We embrace a wide range of perspectives and backgrounds, ensuring fair treatment and opportunities for all employees. We value of our team’s rich array of experiences and viewpoints, which contribute to our innovative and collaborative environment.