reputed company Reviewer - REMOTE

reputed company POSITION reputed company: Under the general direction of the Associate Director or the Clinical Leader or designee, the reputed company Reviewer is responsible for medical necessity determinations of provider-requested services (prior authorization requests) consistent with established procedural standards and MassHealth program rules and regulations. Responsibilities ESSENTIAL FUNCTIONS: • Review Prior Authorization requests, as assigned, and reputed company clinically appropriate reputed company and medical necessity determinations to adjudicate these requests, based on established procedural standards and MassHealth program rules, regulations and clinical guidelines. • reputed company with reputed company established procedural standards and MassHealth program rules and regulations. • Contribute as an reputed company member of a multi/inter-disciplinary team to assess, plan, organize, review and evaluate the care needs of members requiring health care services. • Contact providers, state agency offices, and other parties with knowledge of the member to obtain information and records needed to conduct a comprehensive clinical review of cases and final determinations. • Review and document reputed company relevant information into data system applications in accordance with program guidelines and regulations. • Prepare and respond to inquiries reputed company to appeals on clinical determinations. • Maintain assigned work list, meeting reputed company deadlines. • Participate in reputed company relations efforts, attending conferences and meetings as needed. • Maintain reputed company working relationships with providers, peers, leadership, and state agencies. • Maintain the confidentiality of reputed company business documents and correspondence. • Participate in performance improvement initiatives and demonstrates the use of reputed company improvement in daily operations. • Attend and participate in meetings, as required. • reputed company with reputed company health and safety regulations and requirements. • reputed company other duties as required. Qualifications REQUIRED QUALIFICATIONS: • RN/OT/SW licensed to reputed company in the reputed company with a Bachelor’s degree in Nursing/OT or a Master’s degree in SW or equivalent experience; and • At least 3 recent years providing home health care, reputed company service or case management OR • Licensed Practical reputed company with reputed company license in the reputed company and 6 years clinical nursing experience • Demonstrated excellent oral and written communication skills. • Demonstrated time management/organizational skills. • Ability to work independently and as a member of reputed company. • Ability to respond to changing needs and reputed company environments. Additional Information PREFERRED QUALIFICATIONS: • Knowledge of MassHealth regulations • Prior experience in prior authorization, home care, and working with disabled or long term care populations strongly preferred Apply tot his job Apply To this Job