Clinical Rev II - Case Mgt (20 hours)

Under the general supervision of the Associate Director, or designee, the Clinical Reviewer II is responsible for case consultation by reviewing medical records, assessing the member's needs, and provide resource support This position ensures that eligible members are referred to and receive appropriate services, supplies and equipment based on medical necessity determinations and program regulations.

Contribute as an active member of a multi/inter-disciplinary team to assess, review and evaluate the care needs of members requiring Long Term Services and Supports (LTSS) and other MassHealth services including PCA, HHA DME, Oxygen and Respiratory equipment medical supplies and therapy services

• Conduct on-site visits and telephonic outreach to members and providers in order to review the Member's abilities and environment to determine medical necessity for requested services, supplies and equipment.

• Respond to Prior Authorization (PA) requests to determine and authorize medically necessary services, supplies and equipment for members in accordance with program guidelines and regulations.

• Contact providers and members to obtain information and records needed to conduct a comprehensive clinical review and final determination.

• Review and document all communications and relevant information into data system applications in accordance with program guidelines and regulations.

• Maintain assigned work list, meeting all deadlines.

• 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.

• Participate in public relations efforts, attending conferences and meetings as needed.

• Participates in training and onboarding of new clinical staff

• Maintain positive working relationships with peers, leadership, Members, and relevant informal supports, provider organizations, and state agencies.

• Prepare and respond to inquiries related to appeals on clinical determinations.

• 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 demonstrate 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.

• Perform other similar and related duties as required or as directed.

• Bachelor's Level Degree in Occupational Therapy or Respiratory Therapy with OT/RT License to practice in Massachusetts.

• OR

• Master's Degree in Speech Language Pathology with SLP License to practice in Massachusetts.

• OR

• Doctorate Degree in Physical Therapy with PT License to practice in Massachusetts.

• Expertise in one or more of the following specialty areas: acute medicine, long term care, mental health, disabilities or equivalent

• 5 years' work experience with at least 3 recent years providing direct service or case management

• Knowledge of applicable state regulations

• Ability to travel statewide to member homes or facilities.

• OT role only: extensive statewide travel to conduct on site PCA and HHA evaluations

• Valid Driver's license required

• Experience with Office Application and database

• Experience with prior authorization and/or eligibility determinations

• Extensive experience with program related services/populations. This would include pediatric, young adult, or adult, long term care, disabled populations, medically complex individuals, home care/community settings, brain injury, DME, therapy services, orthotics, prosthetics, PCA, HHA, IADL's and ADLs