Clinical Reviewer I - remote, east coast based (Part time, 20 hours) Job at University of Massachusetts Medical School
University of Massachusetts Medical School Shrewsbury, MA 01545
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 is 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 UMMS/CWM procedures and HIPAA regulations
- Participate in performance improvement initiatives and demonstrates 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
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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