Qureos Mentor

University of Massachusetts

<div>Overview:
<div><div><div><b>
Job Summary</b></div></div><div><div><div><div><div><div><br>
Under the general supervision of the Associate Director, Clinical Coordinator, 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 long term services and supports (LTSS) 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.</div></div></div></div></div></div></div><br>
<div></div>
Responsibilities:
<div><div><div><b>
Major Responsibilities</b></div></div><div><div><div><div><div><div><br>
<ul><li>
Serve as the clinical manager for an assigned caseload of Members.</li></ul></div><div><br>
<ul><li>
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.</li></ul></div><div><br>
<ul><li>
Conduct on-site reviews and assessments of Member&rsquo;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, meeting all established deadlines.</li></ul></div><div><br>
<ul><li>
Prepare and implement Member service records.</li></ul></div><div><br>
<ul><li>
Coordinate, facilitate and monitor the delivery of services to members.</li></ul></div><div><br>
<ul><li>
Review and document all relevant information into data system applications in accordance with program guidelines and regulations.</li></ul></div><div><br>
<ul><li>
Conduct routine and ad-hoc evaluations and re-evaluations of Members&rsquo; services.</li></ul></div><div><br>
<ul><li>
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.</li></ul></div><div><br>
<ul><li>
Evaluate and document the appropriateness of Members&rsquo; services and make modifications, as required.</li></ul></div><div><br>
<ul><li>
Maintain individual records documenting all Member encounters and contacts; write clinical summaries.</li></ul></div><div><br>
<ul><li>
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.</li></ul></div><div><br>
<ul><li>
Prepare and respond to inquiries related to appeals on clinical determinations.</li></ul></div><div><br>
<ul><li>
Maintain positive working relationships with peers, leadership, Members, relevant informal supports, provider organizations, and state agencies.</li></ul></div><div><br>
<ul><li>
Maintain the confidentiality of all business documents and correspondence per UMass Chan Medical School/ForHealth Consulting procedures and HIPAA regulations.</li></ul></div><div><br>
<ul><li>
Participate in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.</li></ul></div><div><br>
<ul><li>
Participates in training and onboarding of new clinical staff</li></ul></div><div><br>
<ul><li>
Comply with established departmental policies, procedures and objectives.</li></ul></div><div><br>
<ul><li>
Perform other duties as required.</li></ul></div></div></div></div></div></div></div><br>
<div></div>
Qualifications:
<div><div><div><b>
Required Qualifications</b></div></div><div><div><div><div><div><div><br>
<ul><li>
RN licensed to practice in Massachusetts</li></ul></div><div><br>
5-7 years of work experience with at least 3 recent years providing direct service or case management to the pediatric, young adult, or adult medically complex population<br>
<ul><li>
</li></ul></div><br>
<div><ul><li>Ability to travel statewide to Member homes and service providers places of business</li></ul></div><div><br>
<ul><li>
Experience with Office Application and database</li></ul></div><div><br>
<ul><li>
Valid Driver&rsquo;s license required</li></ul></div></div></div></div></div></div></div><div></div><div><div><div><b><br>
Preferred Qualifications</b></div></div><div><div><div><div><div><div><br>
<ul><li>
Experience with home care</li></ul></div><div><br>
<ul><li>
Knowledge of applicable state regulations</li></ul></div><div><br>
<ul><li>
Experience with prior authorization and/or eligibility determinations</li></ul></div><div><br>
<ul><li>
Experience with the care of medically complex individuals</li></ul></div></div></div></div></div></div></div><br>
<div></div>
Additional Information:
<div><div><div><b>
Supervision</b></div></div><div><div><div><div><div><b><br>
Supervision Received</b></div></div><div><div><div><div><br>
Supervision received from Clinical Coordinator</div></div></div></div></div></div></div><div></div><div><div><div><div><div><b><br>
Supervision Exercised</b></div></div><div><div><div><div><br>
None</div></div></div></div></div></div></div></div><div></div><div><div><div><b><br>
Environmental Working Conditions</b></div></div><div><div><div><div><div><div><br>
Remote/desk work with statewide travel required</div></div></div></div></div></div></div></div><div></div>

Nurse Rev II-Case Mgt

<div>Overview:
<div><b>
GENERAL SUMMARY OF POSITION:
</b></div><div>Under the general direction of the Manager or designee, the Program Coordinator will be responsible for coordinating assigned program activities. The primary responsibilities of the program coordinator include providing customer service to Medicaid clients to assist them with the Medicare enrollment process, handling in-coming calls from a diverse client population, conducting outreach and follow up calls to clients to ensure successful enrollment in Medicare, updating client records in proprietary database and reporting program activities and results. The Benefit Coordination Consulting (BCC) Program Coordinator will participate in the daily operations of Medicare Eligibility Enhancement Program projects and assist in the project activities relating to cost savings and revenue initiatives both in- and out-of-state.</div>
Responsibilities:
<div><b>
MAJOR RESPONSIBILITIES:</b></div><ul><li>
Coordinate and monitor assigned program activities.</li><li>
Review and analyze data relating to program effectiveness.</li><li>
Make recommendations for changes in procedures and guidelines and formulate strategies for accomplishing program objectives.</li><li>
Provide technical assistance and advice to agency personnel and others concerning assigned programs in order to exchange information, resolve problems and ensure compliance with established policies, procedures and standards.</li><li>
Develop and implement procedures and guidelines to accomplish assigned agency program objectives and goals.</li><li>
Confer with management staff and other agency personnel to determine program requirements and availability of resources and assist in developing program evaluation criteria and standards.</li><li>
Evaluate program activities and make recommendations for program modifications.</li><li>
Review existing regulations that pertain to programs and services and make recommendations for improvements or changes, particularly as it relates to meeting contractual requirements.</li><li>
Comply with established policies, health &amp; safety regulations and requirements, procedures and department objectives.</li><li>
Review and monitor compliance with the federal and state regulations.</li><li>
Maintain the confidentiality of all business documents and correspondence per UMass Chan Medical School/ForHealth Consulting procedures and HIPAA regulations</li><li>
Perform other related program duties as assigned.</li></ul>
Qualifications:
<div><b>
REQUIRED QUALIFICATIONS:</b></div><ul><li>
Bachelor&rsquo;s degree in business or public administration or related field; or equivalent experience.</li><li>
Two years of related experience in business administration, business management or public administration.</li><li>
Ability to understand, apply and explain pertinent laws, rules, regulations, policies, and procedures.</li><li>
Ability to work independently and collaboratively.</li><li>
Ability to relate and communicate well with a diverse client population.</li><li>
Ability to communicate effectively in both writing and oral presentation.</li><li>
Demonstrated ability to work appropriately with confidential information.</li><li>
Skilled in problem solving and team building</li><li>
Effective negotiating skills.</li><li>
Strong interpersonal skills needed to interact with all organizational levels.</li><li>
Demonstrated ability to assess priorities and operate in a flexible manner.</li><li>
Demonstrated experience using computer based tools including email, Microsoft Word, Excel, PowerPoint and database environments.</li></ul><div></div><div><b><br>
PREFERRED QUALIFICATIONS:</b></div><ul><li>
Previous professional experience in customer service or call center role.</li><li>
Experience working with federal and state agencies, preferably health and human services organizations.</li><li>
Knowledge of state and federal health insurance programs.</li><li>
Ability to utilize questioning and listening skills that support effective telephone communication.</li><li>
Ability to apply the proper telephone etiquette to satisfy various client and agency situations.</li><li>
Experience working with Microsoft Access and SQL data environments</li></ul></div>

Medicare Enrollment Support Program Coordinator - REMOTE

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University of Massachusetts

About Company

Nurse Rev II-Case Mgt

Medicare Enrollment Support Program Coordinator - REMOTE