Clinical Reviewer I - Remote

About the position

The Clinical Reviewer I position at UMass Chan 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. The position also includes assisting with appeal preparations and conducting reviews for 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

• General understanding of medical records and clinical review processes
• Ability to work collaboratively in a multi/inter-disciplinary team environment
• Strong organizational and documentation skills
• Excellent communication skills, both verbal and written
• Knowledge of HIPAA regulations and confidentiality requirements

Nice-to-haves

• Experience in health care services or clinical review
• Familiarity with Disability and Community Services cases
• Previous experience in a role involving service authorizations

Benefits

• Work from home option
• Flexible scheduling
• Professional development opportunities