Clinical Eligibility & Quality Advisor

University of Massachusetts Medical School; Westborough (MA); On-site; USD 180,000 - 240,000; Full time

Job summary

University of Massachusetts Medical School seeks a Physician Advisor to review applicant medical records and determine eligibility for benefits and long-term care in line with federal and state guidelines. You will guide reviewers and contribute to clinical quality initiatives.

You will participate in case reviews, help interpret regulations, shape clinical policies, and provide training to new Physician Advisors while collaborating with leadership to address complex cases.

Qualifications

• Board eligible or certified in specialty.
• Minimum of 5 years of experience in direct patient care.
• Ability to plan and prioritize work to meet objectives.
• Excellent problem solving and decision making capabilities.

Responsibilities

• Responsible for determining whether an individual applying for and/or receiving public assistance benefits/services meets specific clinical and functional criteria outlined in federal and state regulations
• Review medical records, approves or denies recommendations made by Registered Nurse Reviewers regarding the status of an applicant or member
• Participates in and advises review team regarding the functional capability of an applicant based upon a comprehensive review of all records
• Contributes to quality improvement initiatives developed within the program or department
• Participates in quality team case reviews
• Collaborate with department leadership in the interpretation of all applicable regulations, development of clinical policies and quality evaluations, and provide feedback to clinical staff regarding clinical policies and the outcomes of quality evaluations
• Evaluates and develops alternatives to address problems and issues as they arise on a case by case basis
• Participates as a member of clinical or case review teams
• Responsible for training new Physician Advisors
• Performs other duties as assigned.

Skills

Clinical decision making

Regulatory interpretation

Quality improvement

Training staff

Team collaboration

Education

Board eligible or certified in area of specialty

Job description

University of Massachusetts Medical School seeks a Physician Advisor to review applicant medical records and determine eligibility for benefits and long-term care in line with federal and state guidelines. You will guide reviewers and contribute to clinical quality initiatives.

You will participate in case reviews, help interpret regulations, shape clinical policies, and provide training to new Physician Advisors while collaborating with leadership to address complex cases.