Under the general supervision of the Associate Director, or designee, the Nurse Reviewer II is responsible for providing administrative case management as part of the Community Case Management Program. This position is responsible for the authorization, coordination and facilitation of community long term care services for program Members. As a member of a multidisciplinary team, the Nurse Reviewer II is responsible for assessing, planning, organizing, reviewing and evaluating the care needs of Members requiring community based services. This position fosters and promotes continuity of care and cooperative partnerships by liaising with nursing providers, state agency staff, acute care hospitals and other programs/organizations involved in the provision of services.
Serve as the clinical manager for an assigned caseload of Members
Contribute as an active member of a multi/inter-disciplinary team to assess, plan, organize, review and evaluate the care needs of Members requiring health care services, to include outpatient and home based therapy services
Conduct on-site reviews and assessments of Member’s community long term care needs to determine medical necessity and clinical eligibility for Community Case Management and Continuous Skilled Nursing Services Determine and authorize services for Members in accordance with program guidelines and regulations
Prepare and implement Member service records
Coordinate, facilitate and monitor the delivery of services to members
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 Members’ services
Contact and engage providers, state agency offices, and Members to obtain information and records needed to conduct a comprehensive clinical review of the case and final determination
Evaluate and document the appropriateness of Members’ services and make modifications, as required
Maintain individual records documenting all Member 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 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 Members, and relevant informal supports, provider organizations, and state agencies
Maintain the confidentiality of all business documents and correspondence per UMMS/CWM 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 similar and related duties as required or as directed.
RN licensed to practice in Massachusetts
Bachelor’s Degree in Nursing or equivalent experience
5 years’ work experience with at least 3 recent years providing direct service or case management to pediatric patients or young adults with special needs
Ability to travel statewide to Member homes and service providers places of business