Remote Utilization Review Rn Jobs in Somerville, MA

Job Summary

Under the general direction of the Associate Director, or designee, the Clinical Coordinator is responsible to develop, prioritize, and oversee staff activities specifically designed to promote the coordination of care for those MassHealth members who have medically complex, chronic or catastrophic illnesses that require a customized approach to how, when, and where they receive medically necessary health care services. This position provides leadership for the ongoing development of clinical competence and practice. In collaboration with colleagues, this position will supervise and implement improvements to clinical review activities.

Major Responsibilities

• Provide clinical direction, supervision, and support to the clinical review team’s determination of eligibility and/or authorize services for members in accordance with program guidelines and regulations.
• Supervise and perform the approval, modification or denial of requested services consistent with established procedural standards and MassHealth program rules and regulations to monitor provider compliance.
• Participate in on-site visits to MassHealth providers, long-term care facilities, rehab facility, acute care facility and/or consumer’s residence, as necessary.
• Collaborate with other Executive Office of Health and Human Services’ Agencies regarding the issues of various MassHealth populations.
• Research MassHealth regulations and interpret these regulations for providers and clinical review team
• Provide clinical support to MassHealth program managers, and design and present training sessions 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 to respond to inquiries pertaining to specific program areas.
• Prepare and respond to inquiries related to appeals following clinical determinations
• Foster team environment, and provide professional and clinical leadership to team members, including consultants, providers and administrative support staff as appropriate.
• Direct team members in identifying and addressing issues involving clinical matters.
• Interface with state agencies and providers regarding clinical determination of medical necessity and program compliance.
• Communicate policy, workflow and organizational changes to team members.
• Provide orientation and ongoing in-service/continuing education programs for team members.
• Conduct performance evaluations of team members.
• Participate in the hiring and termination of team members.
• Work closely with Director and other management staff to ensure clinical integrity is maintained in the clinical eligibility and nurse reviewer processes.
• Maintain confidentiality of all business documents and correspondence.
• In collaboration with the Director and other management staff to coordinate performance improvement and quality assurance activities.
• Attend and participate in meetings as required.
• Prepare written reports/determinations as requested.
• Travel to and from providers’ places of business, state agency offices, long-term care or rehab facilities, acute care facilities and/or consumer’s residence.
• Perform other related duties as required or assigned.

Required Qualifications

BA/BS in a related field or equivalent experience required OR RN licensed to practice in Massachusetts

AND:

• 5-10 years of related work experience with at least 2 years supervisory or management experience in a clinical care coordination role
• Ability to interpret appropriate regulations
• Ability to work independently and collaboratively
• Experience with Word and Excel and other desktop tools
• Ability to travel statewide to member/applicant/participant homes and service providers places of business
• Valid driver’s license required

Preferred Qualifications 

• 3 years of related work experience with prior authorization and/or eligibility determinations for disabled, medically complex, home care, rehab or long term care populations strongly preferred
• Knowledge of MassHealth Hearing and Appeals process preferred
• Knowledge of MassHealth regulations preferred
• Strong analytical and problem solving skills preferred
• Professional certifications are preferred

Supervision

Supervision received from Associate Director

Supervision Exercised

Supervision exercised over a team of clinicians

Environmental Working Conditions

Remote/desk work with- some statewide travel may be required

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