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Clinical Reviewer I – Remote | University of Massachusetts Medical School


Job title: Clinical Reviewer I – Remote

Company: University of Massachusetts Medical School

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

Expected salary:

Location: Shrewsbury, MA

Job date: Thu, 10 Oct 2024 03:52:48 GMT

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