Hybrid Sr. Prior Authorization Nurse at Community Health Network of Connecticut, Inc.

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

Primary Responsibilities: 

• Works collaboratively with Utilization Management staff in conducting medical necessity review activities for HUSKY Health Program members. 
• Processes prior authorization reuests based on DSS coverage limitations and medical necessity criteria.

Tasks Performed: 

• Conducts medical necessity review for rehabilitation services, DME and medical supplies, home care, surgery, genetic testing, and out-of-network services. May review additional services as requested. 
• Uses critical thinking to identify coordination of care issues and gaps in care and collaborates with individuals both within and outside the organization to
• address member needs. 
• Utilizes InterQual and DSS approved medical policies to render determinations.
• Refers cases for physician review when clinical information does not support medical necessity. 
• Mentors clinical staff to promote strong application of clinical judgment, accurate application of criteria and benefit guidelines. 
• Accurately documents review activities. 
• Member and provider letters are clear and member letters are written at contract required reading level. 
• Manages more complex cases. 
• Acts as a clinical resource.
• Performs other duties as assigned. 
• Provides after-hours on call as needed.

Essential Functions: 

• Strong application of clinical judgment and critical thinking to assess medical necessity and gaps in care. 
• Handles more complex referrals. 
• Serves as a clinical resource to other staff and addresses escalated issues requiring review by an RN. 
• Performs quality assurance and monitoring functions for staff as requested.

Desired Education: Four years post-secondary schooling

Desired Degree: Bachelor’s degree preferred 

Desired Major: Nursing

Desired Job Experience: Three to five years related experience with at least three years clinical experience. Managed care experience preferred.

Certifications Required: Active Registered Nurse License

CHNCT Offers Great Benefits:

• Medical, dental and vision coverage options
• Flexible spending and health savings accounts
• Group term life insurance
• A 401(k) plan with company-match and immediate vesting
• Voluntary accidental injury coverage
• Tuition reimbursement and continuing education opportunities
• A generous paid-leave bank and company holidays
• Wellness program

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.