Clinical Reviewer I - Remote

Overview

GENERAL SUMMARY OF POSITION: 

Under the general supervision of the Associate Director, or designee, the Clinical Reviewer I is responsible for reviewing service authorizations and participating in special projects. Using program guidelines and regulations; medical records; and professional clinical judgment, this position authorizes services that is medically necessary for eligible individuals. The Clinical Reviewer I is also responsible for assisting with appeal preparation and completing special projects related to reviews for Disability and Community Services cases.

Responsibilities

MAJOR RESPONSIBILITIES:

• Participate as an active member of a multi/inter-disciplinary team to assess, plan, organize, review and evaluate the care needs of applicants/participants requiring health care services
• Determine and authorize services for applicants/participants in accordance with program guidelines and regulations with increasing independent judgment
• Obtain relevant information and records needed to conduct a comprehensive clinical review of the case and final determination as directed by primary clinical reviewer, and/or Clinical Manager.
• Review and document all relevant information into data system applications in accordance with program guidelines and regulations
• May participate in the preparation of appeals for denied/modified services through communication with state agencies, applicants and other parties as necessary
• Prepare and respond to requests for statistics and resource/service data
• 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
• Maintain positive working relationships with applicant/participants, and 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
• Comply with established departmental policies, procedures and objectives
• Comply with all health, safety and program regulations and requirements
• May participate in public relations efforts, attending conferences and meetings as needed
• Perform other similar and related duties as required or as directed

Qualifications

REQUIRED QUALIFICATIONS:

• RN, LPN or social worker licensed to practice in Massachusetts with an appropriate degree
• 5 years’ work experience with at least 3 recent years providing direct service or case management
• Expertise in one or more of the following specialty areas: acute medicine, long term care, mental health, disabilities or equivalent
• Knowledge of applicable state regulations
• Experience with Office Applications and databases

PREFERRED QUALIFICATIONS:

• Extensive experience with program related services/populations preferred