Clinical Appeals Reviewer - RN or OT

Shrewsbury, Worcester County
Jan 15, 2014
Jobs Outside Higher Education
Businesses & Consultants

CWM’s Disability and Community Services’ (DCS) mission is to enhance access to services that improve the health, well-being and quality of life for the elderly, people with disabilities, complex care needs and other populations. With extensive experience designing, implementing and administering 1915(c) Medicaid waivers, rebalancing programs and other initiatives, DCS offers operational and policy consulting services that address gaps in long-term care services, assists states in balancing services delivered in the home and community settings, coordinates long-term care services including home nursing visits, rehabilitation services and the procurement of medical equipment, provides caregivers with a single point of contact for services and leads multidisciplinary teams focused on addressing community-based clinical services and social needs  for individuals and families.

Due to our continued growth, we are seeking a seasoned Clinical Appeals Reviewer to be responsible for the oversight and adjudication of appeals and grievance cases/matters. You will also:

  • Contribute 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, to include outpatient and home based therapy services and durable medical equipment and orthotic and prosthetic equipment
  • Determine and authorize services for applicants/participants in accordance with program guidelines and regulations, specifically the Personal Care Attendant and Durable Medical Equipment regulations
  • Contact providers, state agency offices and clients 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
  • 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 applicant/participants and relevant informal supports, provider organizations, and state agencies
  • Participate in performance improvement initiatives and demonstrates the use of quality improvement in daily operations

A Bachelor’s degree in Nursing or Occupational Therapy with a current Massachusetts RN/OT license along with 5 years’ work experience providing direct service or case management is required. Expertise in one or more of the following specialty areas: acute medicine, long term care, mental health, disabilities or equivalent is a must. Prior experience with appeals and MassHealth regulations preferred. Ability to travel statewide as needed.