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Under the direction of the Senior Medical Director or designee, the Nurse Manager for the Non-Institutional Provider Review (NIPR) program manages the provider case review process and the staff of the NIPR Team. The NIPR Program is specifically designed to meet MassHealth regulations and the University of Massachusetts Chan School of Medicine’s commitment to MassHealth via its Interagency Service Agreement (ISA). This position provides leadership to and management of the Non-Institutional Provider Review Program including ongoing management and staff development of the Clinical Nurse Reviewers who coordinate and oversee the provider reviews in conjunction with the contracted Quality Improvement Organizations (QIO) and the administrative support staff. The Nurse Manager plans, organizes, directs, and provides oversight of the NIPR Team to ensure that reviews of MassHealth contracted providers are rendering care to MassHealth members that is medically necessary, meets accepted community standards of quality of care, and is provided in a cost-effective manner that meets applicable MassHealth regulations as well as detected possible fraud, waste and abuse. These activities are accomplished in consultation, collaboration and communication with the Office of Clinical Affairs (OCA) Executive Staff, the Provider Integrity Unit, MassHealth Program Managers, EHS Legal, and other state agencies.

• Oversee all aspects of the provider review program and ensure that professional healthcare is practiced in accordance with MassHealth regulations and established community accepted standards of care
• Lead the provider review program in the day to day work of reviewing case reviews
• Develop and monitor provider review program’s goals, provide ongoing feedback and coaching, and conduct staff annual performance reviews
• Assess the quality of provider case reviews through the regular review and analysis of program data
• Manage Professional Nurses and Administrative Support staff. Hire, fire, orient, train, and supervise all the activities of staff Implement disciplinary action as necessary
• Support and ensure compliance with all HR activities including but not limited to annual trainings, compliance and attestations.
• Establish and monitor unit/trial based quality assurance functions, correct deficiencies, investigate related incidents and complaints, prepare follow-up reports, and implement corrective action plans as needed.
• Assist in the design, goal setting and implementation of the annual business plan and performance metrics
• Participates in the development of the budget for assigned cost center; monitors, evaluates and recommends changes within personnel, supplies, and equipment for assigned provider review cases
• Manage unit funding sources by monitoring revenue and expenditure invoice activity; adhere to university, state and funding agency regulations
• Collaborate with the Senior Medical Director, or designee, to determine staffing levels needed to meet case volume and schedules, reassign personnel as required, oversee attendance records, and provide appropriate guidance when needed.
• Manage all regulatory paperwork including if needed applications to the IRB, informed consents, HIPAA Authorization, etc.
• Direct QIOs to contact providers, state agency offices, and other parties, as applicable, to obtain or disseminate information and medical records needed to conduct a comprehensive clinical review of provider cases and final determinations
• Ensure that the terms and conditions contained within the QIO(s) contract(s) are adhered to and that all contractual obligations are met satisfactorily
• Participate in RFA process for QIOs as needed and collaborate with appropriate departments and stakeholders throughout this process
• Support the Board of Hearing (BOH) Administrative Hearing appeals process, including overseeing preparation of the provider case manuals and coordinating NIPR and OCA representation at hearings
• Work to strengthen and advance collaborative relationships with other stakeholder groups including other EHS departments and agencies as well as external organizations.
• 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.
• Comply with all safety and infection control standards appropriate to this position
• Represent the department at administrative meetings within and outside of OCA and UMMS
• Performs other job related duties as required and assigned

REQUIRED EDUCATION
Bachelor’s degree in nursing, or equivalent required.

REQUIRED WORK EXPERIENCE
7- 9 years of related experience
RN, current active license to practice nursing in the Commonwealth of Massachusetts.
Demonstrated communication skills, both oral and written, necessary to interact with faculty, staff and sponsors.
Experience in using computer-based tools; ex. Zoom, Microsoft Office.
Proven ability to effectively handle cases of fraud, waste and abuse in a discreet, confidential, and professional manner.

PREFERRED EDUCATION

Master’s in Business Administration or related field strongly preferred.

PREFERRED WORK EXPERIENCE
3 years of nursing management experience or equivalent.