RN Clinical Coordinator
About The Position
Under the general direction of the Associate Director or designee, the Clinical Coordinator develops, prioritizes, and oversees staff activities to coordinate care for MassHealth members with medically complex, chronic, or catastrophic illnesses who need a customized approach to medically necessary services. The role provides leadership in developing clinical competence and practice and collaborates with colleagues to supervise and improve clinical review activities. The coordinator provides clinical direction and supervision to the clinical review team, oversees determinations and service authorizations, and supports compliance with MassHealth program guidelines and regulations. The position also works with state agencies, providers, program managers, and internal staff; provides training and clinical guidance; contributes to policy and quality improvement; and supervises a team of clinicians. Work is remote/desk-based, with statewide travel to member homes, providers, facilities, and state agency offices as needed.
Requirements
- Bachelor of Arts or Bachelor of Science 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
- 3 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 members’ residences as necessary.
- Collaborate with other Executive Office of Health and Human Services agencies on issues involving 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 providers as needed.
- Review and propose changes to MassHealth program regulations, policies, and related documents.
- Coordinate provider contacts 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 team members with orientation and ongoing in-service and continuing education programs.
- Conduct team member performance evaluations and participate in hiring and termination.
- 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 members’ residences.
- Perform other related duties as required or assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
