Nurse Reviewer II-Case Management

University of Massachusetts Medical School•Westborough, MA

About The Position

Under the general supervision of the Associate Director, Clinical Coordinator, or designee, the Nurse Reviewer II provides administrative case management as part of the Community Case Management Program. The role authorizes, coordinates, and facilitates long-term services and supports (LTSS) for program Members. As part of a multidisciplinary team, the Nurse Reviewer II assesses, plans, organizes, reviews, and evaluates the care needs of Members requiring community-based services. The position promotes continuity of care and cooperative partnerships through liaison with nursing providers, state agency staff, acute care hospitals, and other programs and organizations involved in delivering services. The position receives supervision from the Clinical Coordinator and does not exercise supervision over others. The work environment involves remote or desk work with statewide travel required.

Requirements

Registered Nurse (RN) license to practice in Massachusetts.
5–7 years of work experience, including at least 3 recent years providing direct service or case management to pediatric, young adult, or adult medically complex populations.
Ability to travel statewide to Member homes and service providers’ places of business.
Experience with Office applications and databases.
Valid driver’s license.

Nice To Haves

Experience with home care.
Knowledge of applicable state regulations.
Experience with prior authorization and/or eligibility determinations.
Experience caring for medically complex individuals.

Responsibilities

Serve as clinical manager for an assigned caseload of Members.
Participate as an active member of a multidisciplinary team to assess, plan, organize, review, and evaluate Members’ health care needs, including outpatient and home-based therapy services.
Conduct on-site reviews and assessments of Members’ community long-term care needs to determine medical necessity and clinical eligibility for Community Case Management and Continuous Skilled Nursing Services.
Determine and authorize services in accordance with program guidelines and regulations, meeting established deadlines.
Prepare and implement Member service records.
Coordinate, facilitate, and monitor the delivery of services to Members.
Review and document relevant information in data system applications according to program guidelines and regulations.
Conduct routine and ad hoc evaluations and re-evaluations of Members’ services.
Contact providers, state agency offices, and Members to obtain information and records needed for comprehensive clinical review and final determinations.
Evaluate and document the appropriateness of Members’ services and make modifications as required.
Maintain individual records of Member encounters and contacts, and write clinical summaries.
Promote continuity of care and cooperative partnerships by liaising with health care providers, acute care hospitals, and other programs and organizations involved in service delivery.
Prepare and respond to inquiries related to appeals of clinical determinations.
Maintain positive working relationships with peers, leadership, Members, relevant informal supports, provider organizations, and state agencies.
Maintain confidentiality of business documents and correspondence in accordance with UMass Chan Medical School/ForHealth Consulting procedures and HIPAA regulations.
Participate in performance improvement initiatives and apply quality improvement in daily operations.
Participate in training and onboarding new clinical staff.
Comply with established departmental policies, procedures, and objectives.
Perform other duties as required.