Nurse Reviewer

Job Description

The MassHealth Office of Long Term (Care) Services and Supports (OLTSS) is responsible for managing a robust system of supports for members of all ages who need services to enable them to live with independence and dignity in their daily lives, participate in their communities, and increase their overall quality of life. These services and supports may be provided in the home; in residential, day, and other community-based settings; or in certain facility-based settings, such as nursing homes and chronic disease rehab hospitals. Additionally, OLTSS manages fully-capitated integrated care plans primarily for dually eligible individuals (i.e. Medicare and Medicaid): Senior Care Options (SCO), the One Care Program, and the Program of All-Inclusive Care for the Elderly (PACE). OLTSS also oversees 10 home and community based (HCBS) Medicaid waiver programs that provide specialized services and supports to especially vulnerable OLTSS populations. OLTSS is responsible for ensuring that services provided in any setting and all delivery systems are member-focused, accessible, of the highest quality, and delivered in a cost-effective manner.

This position will audit, inspect, and train MassHealth providers and integrated care plans as well as provide clinical support to OLTSS staff who manage those programs. Additionally, the nurse will provide input on cross-cutting clinical initiatives affecting LTSS programs. This work will require close collaboration with OLTSS program teams and other units within MassHealth, such as Clinical Affairs, as well as MassHealth LTSS Third Party Administrator. The incumbent will report to OLTSS' Clinical Lead, Community and Integrated Care Programs.

Duties and Responsibilities (these duties are a general summary and not all inclusive):

Conducting site and desk audits of LTSS providers and integrated care plans to evaluate quality of care, medical necessity, program eligibility, health and safety, care planning, clinical documentation, staffing, and compliance with MassHealth regulations

Visiting member homes in order to observe care, interview providers and MassHealth members and their caregivers, and review clinical documentation

Providing training, coaching, and other feedback to LTSS providers and integrated care plans based on audit results, MassHealth regulations, clinical best practices, and other OLTSS program needs

Providing clinical support to OLTSS program teams in the day-to-day management of their programs, in the form of reviewing critical incident reports, advising on quality improvement and performance measurement initiatives, responding to providers on clinical issues, assisting with hard-to-place MassHealth members, and advising on clinical impact of changes to regulations and medical necessity criteria.

Reviewing clinical evaluations and eligibility determinations submitted by providers and plans for purposes of confirming eligibility

Serving as clinical subject matter expert on strategic projects, such as the Uniform Core Assessment, development of key performance indicators, or other projects as assigned.

Working with fellow Nurse Reviewers, OLTSS program staff, and the OLTSS Senior Medical Director to identify key clinical problems facing OLTSS programs and offer solutions and recommendations

Evaluating the quality of clinical work conducted by MassHealth's LTSS Third Party Administrator, such as prior authorizations and clinical audits, as well as clinical work conducted by other MassHealth contractors

Documenting audits and reviews using audit tools and standard operating procedures and professional standards and best practices

Preferred Qualifications:

General knowledge of the MassHealth program, including mission, overall structure, benefits, eligibility, payment methodologies, and trends

Specific knowledge of MassHealth long term care programs, including eligibility, provider types, and trends

Knowledge of Geriatric and disability nursing

Ability to translate clinical issues to program staff, providers and plans, advocates

Experience training and coaching health care practitioners

Excellent documentation, presentation, facilitation, and communication skills.

A strong ability to build relationships with internal and external stakeholders and possess the ability to quickly learn their needs

Experience conducting clinical assessments and utilization review

Ability to fill out electronic surveys and assessments in Microsoft Forms, online tools, etc.

Experience overseeing or providing clinical care for an LTSS program or provider

Understanding of the managed health care environment