RN Clinical Coordinator

University of Massachusetts Medical School•Westborough, MA

2d•Remote

About The Position

Under the general direction of the Associate Director or designee, the Clinical Coordinator develops, prioritizes, and oversees staff activities that coordinate care for MassHealth members with medically complex, chronic, or catastrophic illnesses requiring a customized approach to medically necessary health care services. The role provides leadership for the ongoing development of clinical competence and practice and, in collaboration with colleagues, supervises and implements improvements to clinical review activities. The Clinical Coordinator provides clinical direction and supervision to a clinical review team, supports determinations of eligibility and service authorization, and ensures decisions align with program guidelines, procedural standards, and MassHealth rules and regulations. The position also works with providers, state agencies, program managers, and internal staff on clinical determinations, compliance, policy interpretation, training, appeals, and quality improvement. Work is primarily remote or desk-based, with some statewide travel to providers, facilities, agency offices, and members’ or applicants’ residences.

Requirements

BA/BS in a related field or equivalent experience, or an RN license to practice in Massachusetts.
5–10 years of related work experience, including at least 2 years of supervisory or management experience in a clinical care coordination role.
Ability to interpret applicable regulations.
Ability to work independently and collaboratively.
Experience with Word, Excel, and other desktop tools.
Ability to travel statewide to member, applicant, or participant homes and service providers’ places of business.
Valid driver’s license.

Nice To Haves

Three years of related work experience with prior authorization and/or eligibility determinations for disabled, medically complex, home care, rehabilitation, or long-term care populations.
Knowledge of the MassHealth Hearing and Appeals process.
Knowledge of MassHealth regulations.
Strong analytical and problem-solving skills.
Professional certifications.

Responsibilities

Provide clinical direction, supervision, and support to the clinical review team’s eligibility determinations and service authorizations in accordance with program guidelines and regulations.
Supervise and perform approval, modification, or denial of requested services under established procedural standards and MassHealth rules and regulations, monitoring provider compliance.
Participate in on-site visits to MassHealth providers, long-term care, rehabilitation, and acute care facilities, and consumers’ residences as necessary.
Collaborate with other Executive Office of Health and Human Services agencies on issues affecting MassHealth populations.
Research MassHealth regulations and interpret them for providers and the clinical review team.
Provide clinical support to MassHealth program managers and design and present training for in-house staff or MassHealth providers as necessary.
Review and propose changes to applicable MassHealth program regulations, policies, and other documents.
Coordinate contacts with MassHealth providers and respond to inquiries about specific program areas.
Prepare and respond to inquiries related to appeals following clinical determinations.
Foster a team environment and provide professional and clinical leadership to team members, consultants, providers, and administrative support staff as appropriate.
Direct team members in identifying and addressing clinical issues.
Interface with state agencies and providers regarding clinical determinations of medical necessity and program compliance.
Communicate policy, workflow, and organizational changes to team members.
Provide orientation and ongoing in-service and continuing education programs for team members.
Conduct performance evaluations and participate in hiring and termination of team members.
Work with the Director and other management staff to maintain clinical integrity in clinical eligibility and nurse reviewer processes.
Maintain confidentiality of business documents and correspondence.
Coordinate performance improvement and quality assurance activities with the Director and other management staff.
Attend and participate in meetings as required.
Prepare written reports and determinations as requested.
Travel to providers’ places of business, state agency offices, long-term care or rehabilitation facilities, acute care facilities, and consumers’ residences.
Perform other related duties as required or assigned.