Clinical Reviewer I - Remote

About the position The Clinical Reviewer I position at UMass Medical School involves reviewing service authorizations and participating in special projects under the supervision of the Associate Director. The role requires the application of clinical judgment and adherence to program guidelines to authorize medically necessary services for eligible individuals. Additionally, the Clinical Reviewer I assists with appeal preparations and engages in various projects related to Disability and Community Services cases. Responsibilities • Participate as an active member of a multi/inter-disciplinary team to assess, plan, organize, review and evaluate the care needs of applicants/participants requiring health care services , • Determine and authorize services for applicants/participants in accordance with program guidelines and regulations with increasing independent judgment , • Obtain relevant information and records needed to conduct a comprehensive clinical review of the case and final determination as directed by primary clinical reviewer, and/or Clinical Manager , • Review and document all relevant information into data system applications in accordance with program guidelines and regulations , • May participate in the preparation of appeals for denied/modified services through communication with state agencies, applicants and other parties as necessary , • Prepare and respond to requests for statistics and resource/service data , • Foster and promote continuity of care and cooperative partnerships by liaising with health care providers, acute care hospitals and other programs/organizations involved in the provision of services , • Maintain positive working relationships with applicant/participants, and relevant informal supports, provider organizations, and state agencies , • Maintain the confidentiality of all business documents and correspondence per UMass Chan Medical School/ForHealth Consulting procedures and HIPAA regulations , • Participate in performance improvement initiatives and demonstrates the use of quality improvement in daily operations , • Comply with established departmental policies, procedures and objectives , • Comply with all health, safety and program regulations and requirements , • May participate in public relations efforts, attending conferences and meetings as needed , • Perform other similar and related duties as required or as directed Requirements • RN, LPN or social worker licensed to practice in Massachusetts with an appropriate degree , • 5 years' work experience with at least 3 recent years providing direct service or case management , • Expertise in one or more of the following specialty areas: acute medicine, long term care, mental health, disabilities or equivalent , • Knowledge of applicable state regulations , • Experience with Office Applications and databases Nice-to-haves • Extensive experience with program related services/populations preferred

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