Utilization Reviewer Jobs in Springfield, MA (NOW HIRING)

** This is a FULL-TIME or PART-TIME, FIELD/Commuting role where applicants should reside within MA to be considered. **Offering shifts that work with your availability!

About Activate Care:

At Activate Care, we're on a mission to improve health equity and drive improved health outcomes across the country. Our Community Care Record platform, Care Link, enables healthcare and community organizations to coordinate care for populations challenged with health-related social needs (HRSN). Path Assist is our tech-enabled Community Health Worker program for addressing HRSN utilizing an evidence-based, structured intervention. Our goal is simple: address individuals' unmet HRSNs, increase health confidence, improve self-efficacy, and reduce inappropriate healthcare spend.

Role Overview:

This community-focused, Registered Nurse (RN) will travel to members' homes across Massachusetts to complete in-person health assessments for a managed care health plan's dually eligible members. The role specializes in conducting timely, accurate assessments and documenting findings, then handing off to the health plan's care management team. This is assessment and documentation work, not ongoing care management.

Responsibilities:

• Engage with members in their homes and other community settings to complete assessments, with mindfulness of the cultural and linguistic needs of each member.
• Perform required assessments on a timely basis as assigned under the contract, including Uniform Core Assessments (UCA), Functional Assessments (FA), and Comprehensive Assessments, evaluating each member's physical, cognitive, and functional status.
• Document assessments in the health plan's care management platform (GuidingCare) following the provided workflows and resource guides.
• Send a SOAP note to the assigned health plan Care Manager upon assessment completion.
• Submit accurate, complete documentation within 48 hours of each assessment and maintain a high completeness and quality standard as measured through the health plan's review and audit.
• Complete required training and ongoing training to nd maintain system access.
• Routinely travel to members' homes and, or community settings to conduct assessments.
• Report abuse, neglect, or exploitation of older adults and adults with disabilities as a mandated reporter, as required by state law.
• Follow field-safety practices for independent in-home visits and escalate clinical or safety concerns appropriately.
• Adhere to all applicable regulatory, privacy (HIPAA), NCQA, and care management standards
• Maintain licensure and or certifications
• Other duties as assigned.

Requirements

Qualifications & Skills:

• Active Registered Nurse (RN) or higher licensure (e.g., Nurse Practitioner) in good standing with the Commonwealth of Massachusetts.
• Associate of Science degree in nursing from an accredited program is required (BSN preferred).
• Valid driver's license, a personal vehicle, and verifiable insurance are required.
• Minimum of 1 year of clinical experience in a home health setting.
• Minimum of 1 year of experience completing assessments is preferred.
• Prior experience with dual-eligible populations, Medicaid, or Medicare managed care is preferred.
• Assessment-related certification (for example, RAC-CT) is preferred.
• Comfortable working independently in members' homes and managing a daily visit schedule.
• Ability to document accurately and efficiently in an electronic platform via a secure virtual desktop.
• Understanding of Medicare and Medicaid programs and the populations served.
• Strong interpersonal and communication skills to engage members and families.
• Ability to manage multiple assessments and priorities while maintaining attention to detail.
• Awareness of and sensitivity to the diverse backgrounds and needs of the populations served.
• Sound clinical judgment, decision-making, and problem-solving skills.
• Basic proficiency with standard office and communication software.

Working Conditions:

• Must reside within a commutable distance of the assigned Massachusetts territory, and generally within the territory served.
• This is a mobile, field-based position; regular travel to members' homes and community settings is essential and may exceed 50% of the time.
• The role requires maintaining access to high-speed internet at home
• Exposure to weather and to varied home environments; may stand or sit for extended periods.
• Flexible hours based on member availability. Assessments are scheduled in set daytime slots, and evening or weekend availability may be offered depending on the shift chosen.
• Valid driver's license, vehicle, and verifiable insurance are required. Employment is conditional on a successful driver's license record check and verified insurance. Employee is responsible for maintaining during the duration of employment.
• Influenza vaccination is required during flu season (October 1 through March 31) as a condition of employment, consistent with the health plan's requirement for staff serving members in the home. Employees hired during flu season must complete the required vaccination and provide proof of immunization within 30 days of hire. Reasonable accommodations are considered in accordance with applicable law.

Benefits:

• Full-Time & Part-Time roles are eligible for Sign-on Bonus
• Full-Time employees will be offered standard company benefits, PTO, holidays

Diversity & Inclusion:

At Activate Care, we are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates without regard to race, color, religion, sex, pregnancy (including childbirth, lactation, and related medical conditions), national origin, age, physical and mental disability, marital status, sexual orientation, gender identity, gender expression, military, and veteran status, and any other characteristic protected by applicable law. Activate Care believes that diversity and inclusion among our teammates is critical to our success as a company, and we seek to recruit, develop, and retain the most talented people from a diverse candidate pool.

The organization is committed to providing reasonable accommodations to qualified individuals with disabilities throughout the hiring process. If you require an accommodation to participate in the interview process, please let our team know at the time of scheduling. 

The Company will not sponsor applicants for work visas at this time.