Nurse Reviewer II-Case Management

ForHealth Consulting at UMass Chan Medical School; Westborough (MA); A distancia; USD 70.000 - 100.000; Jornada completa

Descripción de la vacante

ForHealth Consulting at UMass Chan Medical School is seeking a Nurse Reviewer II to oversee administrative case management within the Community Case Management Program in Massachusetts. This role collaborates with a multidisciplinary team to assess, plan, and coordinate long-term services for Members and ensure care continuity.

The ideal candidate is an RN licensed in MA with 5–7 years of direct or case management experience in pediatric, young adult, or medically complex populations, and the

Formación

• RN licensed to practice in Massachusetts
• 5-7 years of work experience with direct service or case management to pediatric/young adult/medically complex populations
• Ability to travel statewide to Member homes and service providers
• Experience with Office Applications and databases

Responsabilidades

• Serve as the clinical manager for an assigned caseload of Members.
• Contribute to assess, plan, organize, review and evaluate care needs of Members requiring health care services.
• Conduct on-site reviews and assessments to determine medical necessity and eligibility for Community Case Management and Continuous Skilled Nursing Services.
• Prepare and implement Member service records.
• Coordinate, facilitate and monitor the delivery of services to Members.
• Review and document information into data system applications per guidelines and regulations.
• Conduct routine and ad-hoc evaluations of Members' services.
• Engage providers and state agencies to obtain information for clinical reviews and determinations.
• Evaluate and document appropriateness of Members' services and modify as needed.
• Maintain individual records and write clinical summaries.
• Promote continuity of care by liaising with providers and hospitals.
• Respond to inquiries related to appeals on clinical determinations.
• Maintain relationships with peers, leadership, Members, providers, and state agencies.
• Maintain confidentiality per HIPAA and procedures.
• Participate in performance improvement initiatives and training of new staff.
• Comply with departmental policies and objectives.
• Perform other duties as required

Conocimientos

Case management

Clinical assessment

Educación

RN licensure in Massachusetts

Herramientas

Office applications

Database access

Descripción del empleo

Job Summary

Under the general supervision of the Associate Director, Clinical Coordinator, or designee, the Nurse Reviewer II is responsible for providing administrative case management as part of the Community Case Management Program. This position is responsible for the authorization, coordination and facilitation of long term services and supports (LTSS) for program Members. As a member of a multidisciplinary team, the Nurse Reviewer II is responsible for assessing, planning, organizing, reviewing and evaluating the care needs of Members requiring community-based services. This position fosters and promotes continuity of care and cooperative partnerships by liaising with nursing providers, state agency staff, acute care hospitals and other programs/organizations involved in the provision of services.

Major Responsibilities

• Serve as the clinical manager for an assigned caseload of Members.
• 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, to include outpatient and home based therapy services.
• Conduct on-site reviews and assessments of Members community long term care needs to determine medical necessity and clinical eligibility for Community Case Management and Continuous Skilled Nursing Services Determine and authorize services for Members in accordance with program guidelines and regulations, meeting all established deadlines.
• Prepare and implement Member service records.
• Coordinate, facilitate and monitor the delivery of services to members.
• Review and document all relevant information into data system applications in accordance with program guidelines and regulations.
• Conduct routine and ad-hoc evaluations and re-evaluations of Members services.
• Contact and engage providers, state agency offices, and Members to obtain information and records needed to conduct a comprehensive clinical review of the case and final determination.
• Evaluate and document the appropriateness of Members services and make modifications, as required.
• Maintain individual records documenting all Member encounters and contacts; write clinical summaries.
• 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.
• Prepare and respond to inquiries related to appeals on clinical determinations.
• Maintain positive working relationships with peers, leadership, Members, relevant informal supports, provider organizations, and state agencies.
• Maintain the confidentiality of all business documents and correspondence per UMass Chan Medical School/ForHealth Consulting procedures and HIPAA regulations.
• Participate in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.
• Participates in training and onboarding of new clinical staff
• Comply with established departmental policies, procedures and objectives.
• Perform other duties as required.

Required Qualifications

• RN licensed to practice in Massachusetts
• 5-7 years of work experience with at least 3 recent years providing direct service or case management to the pediatric, young adult, or adult medically complex population
• Ability to travel statewide to Member homes and service providers places of business
• Experience with Office Application and database
• Valid Drivers license required

Preferred Qualifications

• Experience with home care
• Knowledge of applicable state regulations
• Experience with prior authorization and/or eligibility determinations
• Experience with the care of medically complex individuals

Supervision

Supervision received from Clinical Coordinator

Supervision Exercised

None

Environmental Working Conditions

Remote/desk work with statewide travel required

The University of Massachusetts Chan Medical School welcomes all qualified applicants and complies with all state and federal anti-discrimination laws.