RN Clinical Coordinator

University of Massachusetts Medical School; Oregon; Hybrid; USD 85,000 - 110,000; Full time

Job summary

University of Massachusetts Medical School seeks a Clinical Coordinator to lead a clinical review team and coordinate care for MassHealth members with complex needs. You will supervise staff, ensure compliance with program rules, and oversee ongoing clinical review improvements across facilities and residences.

Responsibilities include directing eligibility reviews, approving or denying services, training staff, and collaborating with MassHealth and other agencies while maintaining strict

Qualifications

• BA/BS in a related field or equivalent experience; RN license in MA is acceptable.
• 5-10 years of related work experience with at least 2 years supervisory or management experience.
• Ability to interpret MassHealth regulations and apply them to clinical reviews.
• Travel statewide to member homes and provider sites; valid driver’s license required.

Responsibilities

• Provide clinical direction, supervision, and support to the clinical review team’s determinations.
• Approve, modify or deny services per program rules and MassHealth regulations.
• Collaborate with state agencies and providers; conduct training sessions as needed.
• Interface with multiple facilities and consumer residences; maintain confidentiality.

Skills

Supervisory experience

Independent and collaborative work

Regulatory interpretation

Travel statewide

Analytical thinking

Education

BA/BS in related field or equivalent experience

RN licensed to practice in Massachusetts

Tools

Word

Excel

Job description

Overview

Under the general direction of the Associate Director, or designee, the Clinical Coordinator is responsible to develop, prioritize, and oversee staff activities specifically designed to promote the coordination of care for those MassHealth members who have medically complex, chronic or catastrophic illnesses that require a customized approach to how, when, and where they receive medically necessary health care services. This position provides leadership for the ongoing development of clinical competence and practice. In collaboration with colleagues, this position will supervise and implement improvements to clinical review activities.

Responsibilities

• Provide clinical direction, supervision, and support to the clinical review team’s determination of eligibility and/or authorize services for members in accordance with program guidelines and regulations.
• Supervise and perform the approval, modification or denial of requested services consistent with established procedural standards and MassHealth program rules and regulations to monitor provider compliance.
• Participate in on-site visits to MassHealth providers, long-term care facilities, rehab facility, acute care facility and/or consumer’s residence, as necessary.
• Collaborate with other Executive Office of Health and Human Services’ Agencies regarding the issues of various MassHealth populations.
• Research MassHealth regulations and interpret these regulations for providers and clinical review team
• Provide clinical support to MassHealth program managers, and design and present training sessions for in-house staff or MassHealth providers as necessary.
• Review and propose changes to applicable MassHealth program regulations, policies, and other documents.
• Coordinate contacts with MassHealth providers to respond to inquiries pertaining to specific program areas.
• Prepare and respond to inquiries related to appeals following clinical determinations
• Foster team environment, and provide professional and clinical leadership to team members, including consultants, providers and administrative support staff as appropriate.
• Direct team members in identifying and addressing issues involving clinical matters.
• Interface with state agencies and providers regarding clinical determination of medical necessity and program compliance.
• Communicate policy, workflow and organizational changes to team members.
• Provide orientation and ongoing in-service/continuing education programs for team members.
• Conduct performance evaluations of team members.
• Participate in the hiring and termination of team members.
• Work closely with Director and other management staff to ensure clinical integrity is maintained in the clinical eligibility and nurse reviewer processes.
• Maintain confidentiality of all business documents and correspondence.
• In collaboration with the Director and other management staff to coordinate performance improvement and quality assurance activities.
• Attend and participate in meetings as required.
• Prepare written reports/determinations as requested.
• Travel to and from providers’ places of business, state agency offices, long-term care or rehab facilities, acute care facilities and/or consumer’s residence.
• Perform other related duties as required or assigned.

Qualifications

Required QualificationsBA/BS in a related field or equivalent experience required OR RN licensed to practice in MassachusettsAND:5-10 years of related work experience with at least 2 years supervisory or management experience in a clinical care coordination roleAbility to interpret appropriate regulationsAbility to work independently and collaborativelyExperience with Word and Excel and other desktop toolsAbility to travel statewide to member/applicant/participant homes and service providers places of businessValid driver’s license required

Preferred Qualifications

3 years of related work experience with prior authorization and/or eligibility determinations for disabled, medically complex, home care, rehab or long term care populations strongly preferredKnowledge of MassHealth Hearing and Appeals process preferredKnowledge of MassHealth regulations preferredStrong analytical and problem solving skills preferredProfessional certifications are preferred

Additional Information

SupervisionSupervision received from Associate DirectorSupervision ExercisedSupervision exercised over a team of cliniciansEnvironmental Working ConditionsRemote/desk work with- some statewide travel may be required#LI-AC1