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GENERAL SUMMARY OF POSITION: 

Under the general direction of the Director or designee, the Clinical Nurse Reviewer is responsible for medical necessity determinations of provider-requested services (prior authorization requests) consistent with established procedural standards and MassHealth program rules and regulations.  The Clinical Nurse Reviewer will conduct case reviews, record reviews, and medical necessity determinations and will support Board of Hearing appeals.  This individual will engage in Quality Improvement activities related to the prior authorization process and protect the integrity of the program.

MAJOR RESPONSIBILITIES:

• Review Prior Authorization (PA) 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 medical necessity guidelines. 
• Refer potential denials to Associate Medical Directors (AMDs).
• Document decision in Medicaid Management Information System (MMIS) per established protocols.
• Contribute as an active member of a multi/inter-disciplinary team to assess, plan, organize, review and evaluate the care needs of MassHealth members requiring health care services.
• Contact providers, state agency offices, and other parties, as applicable, to obtain information and medical records needed to conduct a comprehensive clinical review of cases and final determinations. 
• Review and document all relevant information in MMIS or other applicable data system applications in accordance with program guidelines and regulations.
• Prepare and respond to inquiries related to appeals on clinical determinations.
• Support Board of Hearing appeals, including assisting with preparation of cases and representing OCA at hearings.
• Conduct onsite chart reviews and audits at medical facilities and providers’ offices.
• Provide support and backfill for program integrity clinical support activities, as needed, including review and development of fraud/waste/abuse cases.   
• Maintain assigned PA work list and meet all regulatory and mandated turnaround times.
• Maintain positive working relationship with OCA clinicians and consult and collaborate closely with OCA AMD staff on prior authorization reviews.
• 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 demonstrate the use of quality improvement in daily operations.
• Perform other similar and related duties as required or as directed.

REQUIRED QUALIFICATIONS:

• RN licensed to practice in the Commonwealth of Massachusetts
• Bachelor’s degree in Nursing and 5 years clinical nursing experience, or equivalent relevant experience
• Experience in a medical/surgical clinical setting.
• Demonstrated excellent oral and written communication skills. 
• Excellent analytical skills and attention to detail.
• 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.
• Ability to travel within the state of Massachusetts as necessary
• Prior experience in inpatient and/or outpatient rehabilitation services and/or long term acute care hospital services

PREFERRED QUALIFICATIONS:

• Knowledge of MassHealth regulations
• Prior experience in nursing facilities, home care and/or other long term services
• Prior work with disabled or long term care populations highly desirable.