Registered Nurse III

Commonwealth of Massachusetts•Quincy, MA

About The Position

The MassHealth Office of Long Term (Care) Services and Supports (OLTSS) is responsible for managing a robust system of supports for members of all ages who need services to enable them to live with independence and dignity in their daily lives, participate in their communities, and increase their overall quality of life. These services and supports may be provided in the home; in residential, day, and other community-based settings; or in certain facility-based settings, such as nursing homes and chronic disease rehab hospitals. Additionally, OLTSS manages fully-capitated integrated care plans primarily for dually eligible individuals (i.e. Medicare and Medicaid): Senior Care Options (SCO), the One Care Program, and the Program of All-Inclusive Care for the Elderly (PACE). OLTSS also oversees 10 home and community-based (HCBS) waiver programs that provide specialized services and supports to especially vulnerable OLTSS populations. OLTSS is responsible for ensuring that services provided in any setting and all delivery systems are member-focused, accessible, of the highest quality, and delivered in a cost-effective manner. This position will audit, inspect, and train MassHealth providers and integrated care plans as well as provide clinical support to OLTSS staff who manage those programs. Additionally, the nurse will provide input on cross-cutting clinical initiatives affecting LTSS programs. This work will require close collaboration with OLTSS program teams and other units within MassHealth, such as Clinical Affairs, as well as MassHealth LTSS Third Party Administrator. The incumbent will report to OLTSS’ Clinical Lead, Community and Integrated Care Programs.

Requirements

Current and valid registration as a professional nurse under the Massachusetts Board of Registration in Nursing.
Recent graduates from an approved school of nursing must have applied for the first available registered nurse examination.
One year of full-time or equivalent part-time, experience as a registered nurse in a recognized hospital, clinic or medical facility.
Six months of which must have been in a supervisory, administrative or managerial capacity.

Nice To Haves

Demonstrated experience assessing clinical eligibility for hospice services, including review of medical records, diagnoses, prognosis, and applicable program criteria.
General knowledge of the MassHealth program, including mission, overall structure, benefits, eligibility, payment methodologies, and trends.
Specific knowledge of MassHealth long term care programs, including eligibility, provider types, and trends.
Knowledge of Geriatric and disability nursing.
Ability to translate clinical issues to program staff, providers and plans, advocates.
Experience training and coaching health care practitioners.
Excellent documentation, presentation, facilitation, and communication skills.
A strong ability to build relationships with internal and external stakeholders and possess the ability to quickly learn their needs
Experience conducting clinical assessments and utilization review.
Ability to fill out electronic surveys and assessments in Microsoft Forms, online tools, etc.
Experience overseeing or providing clinical care for an LTSS program or provider.
Understanding of the managed health care environment.
Strong analytical skills.
Experience working with cross-functional areas and teams.
Experience using Microsoft suite (Excel, Access, Word, and Microsoft project).

Responsibilities

Conducting site and desk audits of LTSS providers and integrated care plans to evaluate quality of care, medical necessity, program eligibility, health and safety, care planning, clinical documentation, staffing, and compliance with MassHealth regulations.
Visiting member homes in order to observe care, interview providers and MassHealth members and their caregivers, and review clinical documentation.
Providing training, coaching, and other feedback to LTSS providers and integrated care plans based on audit results, MassHealth regulations, clinical best practices, and other OLTSS program needs.
Providing clinical support to OLTSS program teams in the day-to-day management of their programs, in the form of reviewing critical incident reports, advising on quality improvement and performance measurement initiatives, responding to providers on clinical issues, assisting with hard-to-place MassHealth members, and advising on clinical impact of changes to regulations and medical necessity criteria.
Reviewing clinical evaluations and eligibility determinations submitted by providers and plans for purposes of confirming eligibility.
Serving as clinical subject matter expert on strategic projects, such as the Uniform Core Assessment, development of key performance indicators, or projects resulting from the American Rescue Plan Act funding.
Working with fellow Nurse Reviewers, OLTSS program staff, and the OLTSS Senior Medical Director to identify key clinical problems facing OLTSS programs and offer solutions and recommendations.
Evaluating the quality of clinical work conducted by MassHealth’s LTSS Third Party Administrator, such as prior authorizations and clinical audits, as well as clinical work conducted by other MassHealth contractors.
Documenting audits and reviews using audit tools and standard operating procedures and professional standards and best practices.