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Clinical Reviewer I
Job Number: 2019-33081
Category: Healthcare
Location: Shrewsbury, MA
Shift: Day
Exempt/Non-Exempt: Exempt
Business Unit: ForHealth Consulting
Department: Commonwealth Medicine - Disability & Community Service - W401950
Job Type: Full-Time
Salary Grade: 44
Num. Openings: 1
Post Date: July 10, 2019

GENERAL SUMMARY OF POSITION: 

Under the general supervision of the Associate Director, or designee, the Clinical Reviewer I is responsible for reviewing service authorizations and participating in special projects. Using program guidelines and regulations; medical records; and professional clinical judgment, this position authorizes services that is medically necessary for eligible individuals. The Clinical Reviewer I is also responsible for assisting with appeal preparation and completing special projects related to reviews for Disability and Community Services cases.

MAJOR RESPONSIBILITIES:

  • Participate as an active member of a multi/inter-disciplinary team to assess, plan, organize, review and evaluate the care needs of applicants/participants requiring health care services
  • Determine and authorize services for applicants/participants in accordance with program guidelines and regulations with increasing independent judgment
  • Obtain relevant information and records needed to conduct a comprehensive clinical review of the case and final determination as directed by primary clinical reviewer, and/or Clinical Manager.
  • Review and document all relevant information into data system applications in accordance with program guidelines and regulations
  • May participate in the preparation of appeals for denied/modified services through communication with state agencies, applicants and other parties as necessary
  • Prepare and respond to requests for statistics and resource/service data
  • Foster and promote continuity of care and cooperative partnerships by liaising with health care providers, acute care hospitals and other programs/organizations involved in the provision of services
  • Maintain positive working relationships with applicant/participants, and relevant informal supports, provider organizations, and state agencies
  • Maintain the confidentiality of all business documents and correspondence per UMMS/CWM procedures and HIPAA regulations
  • Participate in performance improvement initiatives and demonstrates the use of quality improvement in daily operations
  • Comply with established departmental policies, procedures and objectives
  • Comply with all health, safety and program regulations and requirements
  • May participate in public relations efforts, attending conferences and meetings as needed
  • Perform other similar and related duties as required or as directed

REQUIRED QUALIFICATIONS:

  • RN, LPN or social worker licensed to practice in Massachusetts with an appropriate degree
  • 5 years’ work experience with at least 3 recent years providing direct service or case management
  • Expertise in one or more of the following specialty areas: acute medicine, long term care, mental health, disabilities or equivalent
  • Knowledge of applicable state regulations
  • Experience with Office Applications and databases

PREFERRED QUALIFICATIONS:

  • Extensive experience with program related services/populations preferred

This position completes office-based abbreviated PASRR level 2 reviews.

This is a newly funded position with a July 1, 2019 start date pending the execution of contract.

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