Review Case Manager, Professional Case Review Services

To perform utilization and quality of care review on those cases referred to MassPRO from the Office of Medicaid.
ESSENTIAL / KEY RESPONSIBILITY AREAS:Perform case review, to ensure that the care provided was in accordance with MassHealth regulations.Use clinical based criteria and The Commonwealth of Massachusetts regulations to screen each medical record.Organize case materials for Peer Reviewers, and work with Peer Reviewers to ensure that determinations and findings are made and documented within contract time frames.Prepare documentation that contains case review findings. Include accurate calculations of overpayments.Present case findings to providers and lawyers at informal conferences.Make recommendations to the Manager regarding modifications of the review process to improve efficiency and productivity.Handle confidential and private information appropriately, according to MassPRO’s confidentiality procedures and HIPPA regulations.
QUALIFICATIONS:Current RN license in the Commonwealth of MassachusettsBachelors Degree preferred, Associates Degree or Nursing Diploma considered with appropriate experienceMinimum of three (3) years case management experience requiredWorking knowledge of current Procedural Terminology (CPT) codes preferred.
REQUIREMENTS
Technical Skills:Knowledge of information in healthcare records focusing on quality of care, utilization, and practice patterns.Knowledge of current MassHealth guidelines, regulations and standards for preventative care.Proficient in Microsoft Word and Excel.Healthcare auditing experience preferredExcellent verbal, written skills and telephone skills