Job Description
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 University of Massachusetts Medical School
Job Tags
Remote job, Work experience placement,