Nurse Rev II-Eligibility (Southeast/Metro Boston)

Overview:

POSITION SUMMARY:

FOR MA POSITIONS:

This position ensures that eligible individuals are referred to and receive appropriate services based on medical necessity determinations and program/waiver regulations.

FOR NH POSITIONS:

This position ensures that eligible individuals are referred to and receive appropriate services based on medical necessity determinations and program regulations. This position is based in New Hampshire.

Responsibilities:

ESSENTIAL FUNCTIONS:

• Contribute as an active member of a multi/inter-disciplinary team to assess, plan, organize, review and evaluate clinical eligibility.
• 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.
• Where applicable, determine and authorize services for applicants/participants in accordance with program guidelines and regulations.
• 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.
• Contact providers, state agency offices, and applicants/participants to obtain information and records needed to conduct a comprehensive clinical review of the case and final determination.
• Review and document all relevant information into data system applications in accordance with program guidelines and regulations.
• Maintain individual records documenting all applicant/participant encounters and contacts; write clinical summaries.
• 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.
• Participate in public relations efforts, attending conferences and meetings as needed.
• Maintain positive working relationships with applicant/participants, and relevant informal supports, provider organizations, program consultants 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.
• Perform other duties as required.

Qualifications:

REQUIRED QUALIFICATIONS:

• 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

Additional Information:

PREFERRED QUALIFICATIONS:

• Experience with disabled or long term care populations
• Qualified Intellectual Disabilities Professional (QIDP) or Qualified Mental Health Professional (QMHP)
• Experience in one of the following areas: Long-Term Care, Home Care, Rehab, Brain Injury, Mental Health, Substance Abuse and/or Disabilities.