Provide clinical direction, supervision, and support to the clinical review teams evaluation of the Medicaid providers prepayment request for services and treatment plans.
Supervise the approval, modification or denial of provider-requested services consistent with established procedural standards and MassHealth program rules and regulations to monitor provider compliance.
Participate in on-site visits to MassHealth providers as necessary.
Collaborate with other Executive Office of Health and Human Services Agencies regarding the issues of various MassHealth populations.
Research MassHealth regulations and interpret these regulations for providers.
Provide clinical support to MassHealth program managers, and design and present training sessions for in-house staff or MassHealth providers as necessary.
Review and propose changes to MassHealth program regulations, policies, and other documents.
Coordinate contacts with MassHealth providers to respond to inquiries pertaining to specific program areas.
Foster team environment, and provide professional and clinical leadership to team members, including consultants, providers and administrative support staff as appropriate.
Direct team members in identifying and addressing issues involving clinical matters.
Interface with contractors regarding clinical determination of medical necessity and program compliance.
Communicate policy, workflow and organizational changes to team members.
Provide orientation and ongoing in-service/continuing education programs for team members.
Conduct performance evaluations of team members.
Participate in the hiring and termination of team members.
Work closely with Associate Director and other management staff to ensure clinical integrity is maintained in the clinical eligibility and nurse reviewer processes.
Maintain confidentiality of all business documents and correspondence.
In collaboration with the Associate Director and other management staff to coordinate performance improvement and quality assurance activities.
Attend and participate in meetings as required.
Prepare written reports/determinations as requested.
Travel to and from providers places of business and state agency offices.
Perform other related duties as required or directed.
Under the general direction of the Associate Director or designee
This position provides direct supervision of 8-10 clinical staff as indicated.
ENVIRONMENTAL WORKING CONDITIONS:
Stressful working environment
Must meet court appointed or state agency defined deadlines for the completion of assessments or written reports
Statewide travel including overnights possible.
Knowledge and experience with home care, PCA, diabetes and MassHealth regulations strongly preferred
RN licensed to practice in Massachusetts
Bachelors Degree and 5-10 years of work experience or equivalent
2 years recent supervisory or management experience in a clinical care coordination role
Experience required with Personal Care Attendant Program (PCA), Enteral and Absorbent Products, as well as the Hearing and Appeals process.
Ability to interpret appropriate regulations.
Ability to work independently and collaboratively.
Experience with Word and Excel and other desktop tools.
Valid Massachusetts drivers license required.
Occasional statewide travel required
Knowledge of MassHealth regulations preferred.
Prior experience in prior authorization, home care, and working with disabled or long term care populations strongly preferred.
Strong analytical and problem solving skills preferred.
Professional licensure or certification are preferred
Under the general direction of the Associate Director, or designee, the Clinical Manager (Coordinator) is responsible to develop, prioritize, and oversee staff activities specifically designed to promote the coordination of care for those MassHealth members who have medically complex, chronic or catastrophic illnesses that require a customized approach to how, when, and where they receive medically necessary health care services. This position provides leadership for the ongoing development of clinical competence and practice. In collaboration with colleagues, this position will supervise and implement improvements to clinical review activities.
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.