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Clinical Nurse Reviewer - NIPR (Hybrid - North Quincy, MA)
Job Number: 2024-46250
Category: Healthcare
Location: North Quincy, MA
Shift: Day
Exempt/Non-Exempt: Exempt
Business Unit: ForHealth Consulting
Department: ForHealth Consulting - Office Of Clinical Affairs - W401300
Job Type: Full-Time
Salary Grade: 46
Union Code: Non Union Position -W60- Non Unit Professional
Num. Openings: 1
Post Date: May 31, 2024
Under the general direction of the NIPR Manager or designee, the Clinical Reviewer Auditor is tasked with the responsibility to perform and oversee retrospective, post-payment case reviews of community-based providers who participate in MassHealth. The purpose of these case reviews is to detect possible fraud, waste, and abuse and ensure compliance with regulations governing MassHealth providers as well as to determine whether the services were medically necessary, appropriate, and of a quality that meets professionally recognized standards. This clinical oversight contributes to improving patient care and increasing the overall health of MassHealth members through education to the provider under review.
- Direct MassHealth in policy improvement and procedure initiatives.
- Act as a subject matter expert resource for OCA staff and external agencies regarding fraud, waste, and abuse.
- Direct the development of policy changes based on case reviews.
- Coordinate and support the establishment of departmental policies, procedures, and objectives in conjunction with the NIPR Manager.
- Represent OCA/NIPR on cross-functional committees. Assess and evaluate the care needs of MassHealth members.
- Collaborate with MassHealth's IT analytics for case analysis, including generation of ad hoc reports when necessary.
- Apply laws, regulations, plan policies and guidelines, contract provisions, coding rules, coverage rules, and industry standards for the specific provider type to information gathered during the review process.
- Prepare and present comprehensive case analyses to stakeholders. Issue formal correspondence to providers under review.
- Draft notice of findings by examining medical records against claim lines, noting issues with quality of care, medical necessity, recordkeeping, and billing. Check MassHealth regulations for compliance and include any concerns in the notice. Analyze utilization patterns for possible fraud, waste, and abuse. Collaborate with NIPR's Medical Director to ensure consistent reviews.
- Collaborate with state and federal agencies as needed.
- Develop Board of Hearing (BOH) presentations and participate in appeals.
- Develop quarterly reports for MassHealth.
- Direct Provider Compliance and MassHealth Finance Units to establish provider withholds and recoupments; track and monitor recovery of provider withholds and recoupments.
- Collaborate with EHS Legal during the case review process as needed for potential settlement discussions.
- Collaborate with MassHealth stakeholders throughout the NIPR process.
- Perform other similar and related duties as required or as directed.
REQUIRED QUALIFICATIONS:
- Unrestricted and disciplinary action-free RN, Certified Nurse Practitioner (CNP), or Physician Assistant Certified (PA-C) license to practice in the Commonwealth of Massachusetts.
- Master's degree in business administration, healthcare, nursing, or related field.
- Minimum of 10 years clinical experience.
- Very strong written and oral communication skills; able to create clear and persuasive reports understandable to non-experts.
- Demonstrated strong interpersonal skills.
PREFERRED QUALIFICATIONS:
- Certified Nurse Practitioner or PA-C.
- Understanding of healthcare industry, claims processing, E&M coding, DRGs, and internal investigative process development.
- In-depth knowledge of, and the ability to understand and apply, local, state, and federal laws and regulations.
- In-depth knowledge of, and the ability to understand and apply, MassHealth regulations including transmittal letters and contract provisions.
- Prior utilization review and/or medical coding experience.
- Prior experience with medical review, audits and prior healthcare Fraud, Waste, and Abuse investigation is desirable.
- Prior experience in medical surgical, primary care, emergency room, urgent care, pediatrics, rehabilitation, home care, or other long-term services is desirable.
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