Clinical Eligibility Specialist

4 days ago

Shrewsbury, Massachusetts, United States UMass Chan Medical School Full time
Job Description

UMass Chan Medical School is seeking a skilled Nurse Reviewer II to join our team. As a key member of our multi-disciplinary team, you will be responsible for assessing clinical eligibility, prior authorizations, and providing interval case consultation by reviewing medical records, assessing clients' needs, and providing resource support for program participants/applicants.

Key Responsibilities:
  • Contribute to the assessment, planning, organization, review, and evaluation of clinical eligibility.
  • Conduct on-site reviews and reassessments of applicants/participants/informal supports' ability to assist with providing care when determining medical necessity and clinical eligibility for assigned programs and healthcare services.
  • 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.
  • 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 healthcare 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 applicants/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 demonstrate 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.

Required Qualifications:

  • Bachelor's degree in Nursing or equivalent experience.
  • RN with current licensure to practice in the state of program operations (NH or MA).
  • 5-7 years of related work experience.
  • Knowledge of applicable state regulations.
  • Ability to travel statewide.

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.

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