Nurse Reviewer - Remote Job at University of Massachusetts Medical School, Shrewsbury, MA

YlVYMTJ3dk1DeGNsYjBUSnQrMFBYSUV5M1E9PQ==
  • University of Massachusetts Medical School
  • Shrewsbury, MA

Job Description

Overview

POSITION SUMMARY:

Under the general direction of the Associate Director or the Clinical Leader or designee, the Nurse Reviewer is responsible for medical necessity determinations of provider-requested services (prior authorization requests) consistent with established procedural standards and MassHealth program rules and regulations. 

Responsibilities

ESSENTIAL FUNCTIONS:

  • Review Prior Authorization requests, as assigned, and make clinically appropriate decisions and medical necessity determinations to adjudicate these requests, based on established procedural standards and MassHealth program rules, regulations and clinical guidelines.
  • Comply with all established procedural standards and MassHealth program rules and regulations.
  • 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.
  • Contact providers, state agency offices, and other parties with knowledge of the member to obtain information and records needed to conduct a comprehensive clinical review of cases and final determinations.
  • Review and document all relevant information into data system applications in accordance with program guidelines and regulations.
  • Prepare and respond to inquiries related to appeals on clinical determinations.
  • Maintain assigned work list, meeting all deadlines.
  • Participate in public relations efforts, attending conferences and meetings as needed.
  • Maintain positive working relationships with providers, peers, leadership, and state agencies.
  • Maintain the confidentiality of all business documents and correspondence.
  • Participate in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.
  • Attend and participate in meetings, as required.
  • Comply with all health and safety regulations and requirements.
  • Perform other duties as required.
Qualifications

REQUIRED QUALIFICATIONS:

  • RN/OT/SW licensed to practice in the Commonwealth of Massachusetts with a Bachelor’s degree in Nursing/OT or a Master’s degree in SW or equivalent experience; and
  • At least 3 recent years providing home health care, direct service or case management

OR

  • Licensed Practical Nurse with current license in the Commonwealth of Massachusetts and 6 years clinical nursing experience
  • Demonstrated excellent oral and written communication skills.
  • Demonstrated time management/organizational skills.
  • Ability to work independently and as a member of a team.
  • Ability to respond to changing needs and complex environments.

 

 

 

Additional Information

PREFERRED QUALIFICATIONS:

  • Knowledge of MassHealth regulations
  • Prior experience in prior authorization, home care, and working with disabled or long term care populations strongly preferred

Job Tags

Similar Jobs

WilsonHCG

Low-Voltage Technician - Data Centers Job at WilsonHCG

 ...One of the largest Security and Low Voltage Technologies in the world continues to grow, and has just been awarded new work in the Columbus, Ohio region! This organization is looking for a Lead Low Voltage Technician that can lead the install and service of projects... 

JLG Industries Inc

Services - maintenance repair technician Job at JLG Industries Inc

 ...provider of aviation ground support products, gate equipment and airport services to commercial airlines, airports, air-freight...  ...concise, accurate, and sufficiently detailed data for input of all maintenance information. Provide emergency/unscheduled and scheduled... 

Gpac

Fire Extinguisher Inspector Job at Gpac

F ire Extinguisher Inspector An industry-leading fire protection company is pursuing a Fire Extinguisher Inspector for hire. The candidate should have fire extinguisher inspector experience. This is an attractive opportunity to join a highly reputable organization whose... 

Hunt Hive Talent

Lateral Associate - Corporate - Capital Markets | New York, NY Job at Hunt Hive Talent

 ...Elevate Your Legal Career with Hunt Hive Talent At Hunt Hive Talent Recruiting Agency, we dont just connect talent with opportunitieswe build bridges to success. Our candidates rely on us to open doors to fulfilling careers. If youre ready to take the next step in... 

TekWissen LLC

Data Engineer II Job at TekWissen LLC

 ...NoSQL etc. experience Knowledge of distributed systems as it pertains to data storage and computing Experience with data modeling warehousing and building ETL pipelines Experience working on and delivering end to end projects independently...