Overview:
POSITION SUMMARY:
ForHealth Consulting at UMass Chan Medical School is seeking a detail-oriented Nurse Reviewer II with experience caring for individuals with complex medical needs to join our Community Case Management Program. In this role, you will manage a caseload of members, ensuring they receive the long-term services and supports (LTSS) they need to thrive in the community. This position combines the flexibility of remote work with meaningful field interactions through home and site visits.
You’ll play a key role on a multidisciplinary team - assessing, planning, coordinating, and authorizing care for individuals with complex medical needs, while collaborating closely with providers, state agencies, and other healthcare partners to ensure continuity and quality of care.
Responsibilities:
MAJOR RESPONSIBILITIES: - Serve as the clinical manager for an assigned caseload of Members.
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- 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.
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- Conduct on-site reviews and assessments of Member’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.
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- Prepare and implement Member service records.
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- Coordinate, facilitate and monitor the delivery of services to members.
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- Review and document all relevant information into data system applications in accordance with program guidelines and regulations.
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- Conduct routine and ad-hoc evaluations and re-evaluations of Members’ services.
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- 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.
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- Evaluate and document the appropriateness of Members’ services and make modifications, as required.
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- Maintain individual records documenting all Member encounters and contacts; write clinical summaries.
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- 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.
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- Prepare and respond to inquiries related to appeals on clinical determinations.
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- Maintain positive working relationships with peers, leadership, Members, relevant informal supports, provider organizations, and state agencies.
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- Maintain the confidentiality of all business documents and correspondence per UMass Chan Medical School/ForHealth Consulting procedures and HIPAA regulations.
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- Participate in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.
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- Participates in training and onboarding of new clinical staff
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- Comply with established departmental policies, procedures and objectives.
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- Perform other duties as required.
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Qualifications:
REQUIRED QUALIFICATIONS:
- RN licensed to practice in Massachusetts
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- 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
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- Ability to travel statewide to Member homes and service providers places of business
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- Experience with Office Application and database
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- Valid Driver’s license required
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PREFERRED QUALIFICATIONS:
- Experience with home care
- Knowledge of applicable state regulations
- Experience with prior authorization and/or eligibility determinations
- Experience with the care of medically complex individuals
Additional Information:
Why Join Us
At ForHealth Consulting, part of UMass Chan Medical School, we are dedicated to advancing health and well-being across Massachusetts communities. You’ll be part of a mission-driven organization that values collaboration, innovation, and compassion in care management.
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