Clinical Eligibility Specialist
5 days ago
The University of Massachusetts Medical School seeks a highly skilled Clinical Eligibility Specialist to join our team. As a key member of our review process, you will be responsible for assessing clinical eligibility, prior authorizations, and providing case consultation by reviewing medical records and providing resource support for program participants.
Responsibilities:- Conduct on-site reviews and reassessments of applicant/participant/informal supports ability to assist with providing care when determining the medical necessity and clinical eligibility for assigned program and health care services.
- Review and document all relevant information into data system applications in accordance with program guidelines and regulations.
- Conduct routine and ad-hoc evaluations and re-evaluations of applicants/participants services.
- 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, long term care facilities and other programs/organizations involved in the provision of services.
- 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.
- Bachelor's degree in Nursing or equivalent experience
- RN with current licensure to practice in state of program operations (NH or MA)
- 5-7 years of related work experience
- Knowledge of applicable state regulations
- Ability to travel statewide
- Experience with Office Application and database
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Clinical Reviewer Specialist
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3 weeks ago
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