Clinical Reviewer I - Remote
Minimum Salary: US-MA-Shrewsbury
Job Location: 2 weeks ago (10/7/2024 5:06 PM)
| Requisition Number | 2024-47058 |
| # of Openings | 1 |
| Posted Date | Day |
| Shift | Exempt |
Overview
GENERAL SUMMARY OF POSITION: Under the general supervision of the Associate Director, or designee, the Clinical Reviewer I is responsible for reviewing service authorizations and participating in special projects. Using program guidelines and regulations, medical records, and professional clinical judgment, this position authorizes services that are medically necessary for eligible individuals. The Clinical Reviewer I is also responsible for assisting with appeal preparation and completing special projects related to reviews for Disability and Community Services cases.
Responsibilities
MAJOR RESPONSIBILITIES:
- Participate as an active member of a multi/inter-disciplinary team to assess, plan, organize, review and evaluate the care needs of applicants/participants requiring health care services.
- Determine and authorize services for applicants/participants in accordance with program guidelines and regulations with increasing independent judgment.
- Obtain relevant information and records needed to conduct a comprehensive clinical review of the case and final determination as directed by primary clinical reviewer, and/or Clinical Manager.
- Review and document all relevant information into data system applications in accordance with program guidelines and regulations.
- May participate in the preparation of appeals for denied/modified services through communication with state agencies, applicants, and other parties as necessary.
- 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, and other programs/organizations involved in the provision of services.
- Maintain positive working relationships with applicant/participants, and relevant informal supports, provider organizations, 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.
- May participate in public relations efforts, attending conferences and meetings as needed.
- Perform other similar and related duties as required or as directed.
Qualifications
REQUIRED QUALIFICATIONS:
- RN, LPN, or social worker licensed to practice in Massachusetts with an appropriate degree.
- 5 years' work experience with at least 3 recent years providing direct service or case management.
- Expertise in one or more of the following specialty areas: acute medicine, long-term care, mental health, disabilities, or equivalent.
- Knowledge of applicable state regulations.
- Experience with Office Applications and databases.
PREFERRED QUALIFICATIONS:
- Extensive experience with program related services/populations preferred.
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