Skip to main content

This job has expired

Nurse Reviewer

Employer
University of Massachusetts Medical School
Location
333 South St

View more

Administrative Jobs
Institutional & Business Affairs, Health & Medical Services
Employment Type
Full Time
Institution Type
Four-Year Institution
Send job

Job Details

Overview

POSITION SUMMARY: 

Under the general direction of the Associate Director or the Clinical Leader or designee, the Nurse Reviewer is responsible for medical necessity determinations of provider-requested services (prior authorization requests) consistent with established procedural standards and MassHealth program rules and regulations. 

Responsibilities

ESSENTIAL FUNCTIONS:

  • Review Prior Authorization requests, as assigned, and make clinically appropriate decisions and medical necessity determinations to adjudicate these requests, based on established procedural standards and MassHealth program rules, regulations and clinical guidelines.
  • Comply with all established procedural standards and MassHealth program rules and regulations.
  • 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.
  • Contact providers, state agency offices, and other parties with knowledge of the member to obtain information and records needed to conduct a comprehensive clinical review of cases and final determinations.
  • Review and document all relevant information into data system applications in accordance with program guidelines and regulations.
  • Prepare and respond to inquiries related to appeals on clinical determinations.
  • Maintain assigned work list, meeting all deadlines.
  • Participate in public relations efforts, attending conferences and meetings as needed.
  • Maintain positive working relationships with providers, peers, leadership, and state agencies.
  • Maintain the confidentiality of all business documents and correspondence.
  • Participate in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.
  • Attend and participate in meetings, as required.
  • Comply with all health and safety regulations and requirements.
  • Perform other duties as required.
Qualifications

REQUIRED QUALIFICATIONS:

  • RN/OT/SW licensed to practice in the Commonwealth of Massachusetts with a Bachelor’s degree in Nursing/OT or a Master’s degree in SW or equivalent experience; and
  • At least 3 recent years providing home health care, direct service or case management

                                    OR                                                                                                                                          

  • Licensed Practical Nurse with current license in the Commonwealth of Massachusetts and 6 years clinical nursing experience
  • Demonstrated excellent oral and written communication skills.
  • Demonstrated time management/organizational skills.
  • Ability to work independently and as a member of a team.
  • Ability to respond to changing needs and complex environments.

 

 

 

Additional Information

PREFERRED QUALIFICATIONS:

  • Knowledge of MassHealth regulations
  • Prior experience in prior authorization, home care, and working with disabled or long term care populations strongly preferred

Organization

Realize Your Opportunities – A Career at UMASS Medical School

Inside Workings at UMASS Medical School

The University of Massachusetts Medical School (UMMS), the Commonwealth's only public medical school, is proud of our role in serving the people of Massachusetts. Although, its the inside workings of UMMS that makes the difference.

Mission and Culture

  • We’re serious about our mission and about our people. 
  • Real World Impact - Our people get excited about our mission of real-world impact in health sciences education, research and public service.
  • International Prominence and New Opportunities - As this institution has grown to national – and international – prominence, we’ve found new opportunities to train tomorrow’s physicians, nurses and scientists,  discover causes of and cures for disease and help improve the quality of health care.
  • Deep Commitment - With our clinical partner, UMass Memorial Health Care, and our other teaching affiliates, we share a deep commitment to national distinction in patient care.
  • Valued Partnerships – UMMS partners with Commonwealth Medicine, the health care consulting arm of UMMS. Also, UMMS partners with MassBiologics in scientific collaborations, technology management and creating partnerships for the development of products for the benefit of patients.  These valued partnerships help us to provide services and programs to help meet our needs at UMMS and the public.
  • Proud Contributors - People at UMMS enjoy the feeling of going to work every day knowing what they do is truly important and worthwhile.
  • Complementary and Inseparable - These varied parts of our mission and culture are complementary and inseparable.                 

Careers

UMMS, the state’s first and only public academic health sciences center, educates physicians, scientists and advanced practice nurses to heal, discover, teach and care, with compassion.  UMMS is a world-class institution with opportunities to match. 

Competitive Compensation – UMMS offers salaries that are competitive with Worcester-area employers. When combined with our generous benefits, perks, and paid time off, many job seekers are surprised to find a total rewards package that matches or exceeds their current situation.

Targeted Hiring Process – At UMMS, there are actually multiple hiring processes for different segments of our workforce.  In nearly all cases, UMMS hiring process is decentralized, with qualified candidates screened and referred to an academic officer or manager with hiring authority.

24/7 Access to Employment Opportunities – iCIMS is our online job search and application system.  iCIMS is available 24/7 to provide you with a convenient and up-to-date view of the available employment opportunities across our campuses. Updates are made daily and include all faculty and non-faculty position listings from every school and department within the UMMS. When you identify a position you are interested in and qualified for, apply online. New opportunities become available frequently so it pays to check back often!

Benefits

With outstanding benefits, competitive pay, extensive learning opportunities, and a stimulating and attractive work environment, UMMS may be exactly the employer you’ve been looking for.

• Superior Benefits - UMMS offers a wide range of benefits and perks that invite comparison with the best employers in the Worcester area – and with academic institutions anywhere. UMMS provides superior medical and dental coverage for you and your family, fully funded retirement plans, generous time off, a Tuition Assistance Plan – and much more.

• People Centered - UMMS is an employer, but it is also a community. Its comprehensive medical and dental benefits, retirement plans, and even paid holidays reflect an institution built around people, with a deep respect for their differences and needs.

• Commitment to Healthy Living - UMMS provides resources to help you balance work and life and encourages healthy living through great programs and discounts for fitness, physical activity, weight management, nutritional counseling and general wellness available through our health insurance plans.

• Breadth of Offerings - Above all, the breadth of UMMS offerings set the School apart and makes it an environment favored by all sorts of smart, career-savvy people.

Apply for a Job

As an equal opportunity and affirmative action employer, UMMS recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives and backgrounds.

Online - To view all job opportunities and apply online, visit www.umassmed.edu/hr and click on the “Careers” tab.

Start Now and Realize Your Opportunities!

A History of Making Vital Improvements - UMASS Medical School Milestones

1962: Legislation establishes University of Massachusetts Medical School
1970: First medical students begin classes in Shaw Building
1974: First class graduates 16 MDs
1979: PhD program begins
1986: Graduate School of Nursing opens
1986: PhD program becomes Graduate School of Biomedical Sciences
1994: Graduate School of Nursing initiates PhD program
1998: UMass Clinical System and Memorial Health Care merge to form UMass Memorial Health Care
2001: Lazare Research Building opens
2002: Campus Modernization begins on the University Campus
2004: Graduate Entry Pathway Program established at the Graduate School of Nursing
2005: PhD Program in Clinical & Population Health Research established at the Graduate School of Biomedical Sciences
2005: Massachusetts Biologic Laboratories opens new manufacturing and filling facility in Mattapan
2006: Craig Mello, PhD, Blais University Chair in Molecular Medicine and Howard Hughes Medical Institute Investigator, is awarded the Medical School's first Nobel Prize. Dr. Mello shared the 2006 Nobel Prize in Physiology or Medicine with Andrew Fire, PhD, of Stanford University, for their discoveries related to RNA interference.
2007: Michael F. Collins, MD, is named chancellor and Terence R. Flotte, MD, is named dean of the School of Medicine.  
2009: Groundbreaking for the Albert Sherman Center, a 500,000-square-foot research and education facility slated for completion in 2012.
2010: Ambulatory Care Center opens
2012: The Albert Sherman Center, a 500,000-square-foot research and education facility, completed and opens

Send job

Get job alerts

Create a job alert and receive personalized job recommendations straight to your inbox.

Create alert