Nurse Rev II-Eligibility

POSITION SUMMARY: 

FOR MA POSITIONS:

Under the general supervision of the Associate Director, or designee, the Nurse Reviewer II is responsible for assessing clinical eligibility, prior authorizations and providing interval case consultation by reviewing medical records, assessing the client’s needs, and providing resource support for program participants/applicants. This position ensures that eligible individuals are referred to and receive appropriate services based on medical necessity determinations and program/waiver regulations.

FOR NH POSITIONS:

Under the general supervision of the Associate Director, or designee, the Nurse Reviewer II is responsible for assessing clinical eligibility, including nursing facility level of care determinations and pre-admission screening resident reviews by conducting face to face evaluation and reviewing nursing facility medical records. This position ensures that eligible individuals are referred to and receive appropriate services based on medical necessity determinations and program regulations.  This position is based in New Hampshire.

ESSENTIAL FUNCTIONS:

• Contribute as an active member of a multi/inter-disciplinary team to assess, plan, organize, review and evaluate clinical eligibility.
• Conduct on-site reviews and reassessments of applicant/participant/informal supports’ ability to assist with providing care when determining the medical necessity and clinical eligibility for assigned program and health care services.
• Where applicable, determine and authorize services for applicants/participants in accordance with program guidelines and regulations.
• 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 applicants/participants services.
• Contact providers, state agency offices, and applicants/participants to obtain information and records needed to conduct a comprehensive clinical review of the case and final determination. 
• Review and document all relevant information into data system applications in accordance with program guidelines and regulations.
• Maintain individual records documenting all applicant/participant encounters and contacts; write clinical summaries.
• 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, long term care facilities and other programs/organizations involved in the provision of services.
• Participate in public relations efforts, attending conferences and meetings as needed.
• Maintain positive working relationships with applicant/participants, and relevant informal supports, provider organizations, program consultants 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.
• Perform other duties as required.

REQUIRED QUALIFICATIONS:

• Bachelor’s degree in Nursing or equivalent experience
• RN with current licensure to practice in state of program operations (NH or MA)
• 5-7 years of related work experience
• Knowledge of applicable state regulations
• Ability to travel statewide
• Experience with Office Application and database

PREFERRED QUALIFICATIONS:

• Experience with disabled or long term care populations
• Qualified Intellectual Disabilities Professional (QIDP) or Qualified Mental Health Professional (QMHP)
• Experience in one of the following areas:  Long-Term Care, Home Care, Rehab, Brain Injury, Mental Health, Substance Abuse and/or Disabilities.
• Targeted geograhic area- Southeastern MA & Cape Cod