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

aTNXb0Nkd2RaU1FXUmNOREN2eFVIdmZORnc9PQ==
  • 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

Sideworx Connect USA

Roustabout and rig up crew-completions Job at Sideworx Connect USA

Job Title: Roustabout and Rig Up/Rig Out Fracing Location: Williston, North Dakota Company: Sideworx Connect Position Type: Temporary --- Job Overview: Sideworx Connect is seeking dedicated and hardworking individuals for the position of Roustabout and...

Seekmate

Content Writer Job at Seekmate

 ...content for various platforms, including blog posts, articles, and social media posts. Conduct research to stay up-to-date on industry...  ...to improve online visibility. Collaborate with the marketing team to ensure content aligns with overall marketing goals.... 

Golub & Company

Leasing Consultant (Gold Coast) Job at Golub & Company

Chicago-based Golub & Company LLC and its affiliates are active in key markets across the United States in real estate development, acquisitions, asset and property management, leasing and corporate real estate services.The Company has developed, owned or managed more... 

CSG Partners

Investment Banking Analyst Job at CSG Partners

 ...Investment Banking Analyst (Immediate Hire) We're looking for diligent, coachable, and determined financial services professionals who have already started their careers at major investment banks, accounting firms, or related consultancies. CSG offers a hands-on... 

Zeeba Solutions

Now Hiring Remote Customer Service Consultants! Job at Zeeba Solutions

 ...greater flexibility and control over your work? We are on the hunt for Remote Customer Service...  ...Benefits Work from home in a relaxed environment Save time and...  ...Flexible schedule with options to work nights and weekends Create the best schedule...