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DME Specialist
Organization Overview
Commonwealth Care Alliance is a rapidly growing nonprofit organization providing integrated health care and social support services to people with complex medical needs. Our patients are seniors and persons with disabilities covered under Medicaid or both Medicaid and Medicare. Our innovative care model is nationally recognized for its effectiveness in improving health outcomes for these vulnerable populations.
Our unique care model is empowering for our employees as well as our members. Whether you are a clinical or administrative professional, all of us at Commonwealth Care Alliance receive the satisfaction of knowing our work truly makes a difference. We enjoy a company culture of passionate advocacy in a supportive work environment with opportunities for growth and learning, competitive salaries, and a generous and comprehensive benefit package.

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 DME Specialist is responsible for applying benefit administration policy guidelines to requests received for durable medical equipment (DME) authorizations.
The DME Specialist reports to the DME Supervisor.
Key Responsibilities
  • Conducts decision review for services requiring prior authorization in DME, leveraging technology, guidelines and resources as available
  • Applies clinical and benefit administration policy guidelines to requests for authorizations
  • Processes orders for supplies, equipment and nutritional supplements based on referrals and authorizations; leverages preferred providers and clearly notes rationale for use of non-preferred providers if/when used
  • Serves as subject matter expert in DME within CCA
  • Assures proper, accurate and timely documentation in the medical record
  • Works closely with DME Supervisor to facilitate escalated reviews in accordance to Standard Operating Procedures, including denials
  • Communicates results of reviews in the medical record for the primary care team and clinical reviewers
  • Assesses need for additional structured clinical data for completion of service decision request
  • Handles all authorization requests timely and accurately, adhering to performance and operational measures
  • Follows department and organizational policies and procedures as well as adheres to all applicable regulatory, contractual and compliance requirements
  • Performs all activities with closed loop processes
  • Conducts follow-up telephone calls with members to ensure satisfaction with equipment purchases/modification and track on spreadsheet; brings concerns to supervisor as necessary
Education Requirements
  • Associate’s Degree or equivalent experience required
  • Bachelor’s Degree preferred
Experience Requirements
  • 2+ years in health care environment.
  • Knowledge and experience with DME/medical supplies and Medicare/MassHealth guidelines strongly preferred
  • Experience with disability issues preferred
Knowledge, Skills and Abilities
  • Proven skills and judgment necessary for independent decision making
  • Strong organizational, time management and problem solving skills
  • Ability to function effectively within a multi-disciplinary team
  • Effective oral and written skills
  • Strong interpersonal and customer relations skills
  • Comfort working with DME vendors, verifying accuracy of products and quotes
  • Demonstrated proficiency with Microsoft Excel, Word and Outlook
Working Conditions
  • Office environment
Language Requirements
  • English required, bilingual preferred
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