Clinical Reviewer II (DME/Therapy)
GENERAL SUMMARY OF POSITION:
The incumbent provides clinical review for Disability and Community Services for the Medicaid services including outpatient and home based physical therapy, durable medical equipment and orthotic and prosthetic equipment. As a member of a multi/inter-disciplinary team, this position is responsible for assessing, planning, organizing, reviewing, and evaluating the care needs of applicants/participants requiring heath care services. This position is also responsible for ensuring compliance with all applicable state and federal laws and regulations governing long term care services for program applicants and members. Responsibilities may also include the adjudication of appeals for therapy services, DME and orthotic/prosthetic equipment. A physical therapist with a strong background in the use and/or evaluation for durable medical equipment including manual and power wheelchairs, orthotic and prosthetic equipment and the prior authorization process, is strongly preferred.
- 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
- 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
- Participates in the appeals process for denied/modified services and equipment 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.
- 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
- 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.
- OT/PT/RT/SLP licensed to practice in Massachusetts with a Bachelor’s degree in OT/PT/RT/
- or a Master’s Degree in SLP with expertise in one or more of the following specialty areas: acute medicine, long term care, mental health, disabilities or equivalent
- 5 years’ work experience with at least 3 recent years providing direct service or case management for a variety of medical equipment
- Knowledge of applicable state regulations for DME/Therapy
- Experience with Office Applications and databases
- A physical therapist with a strong background in the use and/or evaluation for durable medical equipment including manual and power wheelchairs, orthotic and prosthetic equipment and the prior authorization process, is strongly preferred.