Job Description

Nurse Reviewer II

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.

Responsibilities

Essential Functions:

• 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 Member's 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.

Qualifications

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 Driver's 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

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