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GENERAL SUMMARY OF POSITION: 

Under the direction of the Associate Director or their designee, the Nurse Reviewer will support MassHealth’s Community Case Management program for medically complex individuals.

This is an office based Clinical Reviewer position supporting the Community Case Management (CCM) Clinical Managers.  The role will include, though will not be limited to, adjudication of Prior Authorization requests, claims review, and review of Skilled Nursing notes to support the CCM CM Assessments.

MAJOR RESPONSIBILITIES:

• Review Prior Authorization requests, as assigned, and make clinically appropriate decisions and medical necessity determinations to adjudicate these requests, based on established procedural standards and MassHealth program rules, regulations and clinical guidelines.
• Comply with all established procedural standards and MassHealth program rules and regulations.
• Contribute as an active member of a multi/inter-disciplinary team to assess, plan, organize, review and evaluate the care needs of members requiring health care services.
• Contact providers, state agency offices, and other parties with knowledge of the member to obtain information and records needed to conduct a comprehensive clinical review of cases and final determinations.
• Review and document all relevant information into data system applications in accordance with program guidelines and regulations.
• Prepare and respond to inquiries related to appeals on clinical determinations.
• Maintain assigned work list, meeting all deadlines.
• Participate in public relations efforts, attending conferences and meetings as needed.
• Maintain positive working relationships with providers, peers, leadership, and state agencies.
• Maintain the confidentiality of all business documents and correspondence.
• Participate in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.
• Attend and participate in meetings, as required.
• Comply with all health and safety regulations and requirements.
• Perform other similar and related duties as required or as directed.

REQUIRED QUALIFICATIONS:

• RN/OT/SW licensed to practice in the Commonwealth of Massachusetts with a Bachelor’s degree in Nursing/OT or a Master’s degree in SW or equivalent experience; and
• At least 3 recent years providing home health care, direct service or case management

                                    OR                                                                                                                                          

• Licensed Practical Nurse with current license in the Commonwealth of Massachusetts and 6 years clinical nursing experience
• Demonstrated excellent oral and written communication skills.
• Demonstrated time management/organizational skills.
• Ability to work independently and as a member of a team.
• Ability to respond to changing needs and complex environments.

PREFERRED QUALIFICATIONS:

• Knowledge of MassHealth regulations
• Prior experience in prior authorization, home care, and working with disabled or long term care populations strongly preferred