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 Strong analytical skills. Experience working with cross-functional areas and teams. Experience using Microsoft suite (Excel, Access, Word, and Microsoft project). Special Requirements: Licensed Registered Nurse /TO APPLY:/ /__/ Please upload both Resume and Cover Letter for this position when applying. First consideration will be given to those applicants that apply within the first 14 days. /About MassHealth:/ The mission of MassHealth is to improve the health outcomes of our diverse members, their families, and their communities by providing access to integrated health care services that sustainably promote health, well-being, independence, and quality of life. For more information about our agency and programs please visit: www.mass.gov/masshealth Pre-Offer Process: A criminal background check will be completed on the recommended candidate as required by the regulations set forth by the Executive Office of Health and Human Services prior to the candidate being hired. For more information, please visit http://www.mass.gov/hhs/cori _ Education, licensure and certifications will be verified in accordance with the Human Resources Division's Hiring Guidelines. Education and license/certification information provided by the selected candidate(s) is subject to the Massachusetts Public Records Law and may be published on the Commonwealth's website. If you require assistance with the application/interview process and would like to request an ADA accommodation, please click on the link and complete theADA Reasonable Accommodation Request Form. For questions regarding this requisition, please the contact the Executive Office of Health and Human Services Human Resources at 1-800-510-4122 and select option #4. Applicants should upload acover letterandresumefor the Nurse Reviewer requisition. First consideration will be given to those applicants that apply within the first 14 days. MINIMUM ENTRANCE REQUIREMENTS: Applicants must have at least (A) one year of full-time or equivalent part-time, experience as a registered nurse in a recognized hospital, clinic or medical facility, and (B) six months of which must have been in a supervisory, administrative or managerial capacity. SPECIAL REQUIREMENTS FOR ALL LEVELS IN SERIES: Current and valid registration as a professional nurse under the Massachusetts Board of Registration in Nursing.Recent graduates from an approved school of nursing must have applied for the first available registered nurse examination. Based on assignment, possession of a current and valid Massachusetts Motor Vehicle Operator's license may be required. Salary placement is determined by a combination of factors, including the candidate's years of directly related experience and education, and alignment with our internal compensation structure as set forth by the Human Resources Division's Hiring Guidelines. For all bargaining unit positions (non-management), compensation is subject to the salary provisions outlined in the applicable collective bargaining agreement and will apply to placement within the appropriate salary range/./ Comprehensive Benefits When you embark on a career with the Commonwealth, you are offered an outstanding suite of employee benefits that add to the overall value of your compensation package. We take pride in providing a work experience that supports you, your loved ones, and your future. Want the specifics? _Explore our Employee Benefits and Rewards! An Equal Opportunity / Affirmative Action Employer. Females, minorities, veterans, and persons with disabilities are strongly encouraged to apply. The Commonwealth is an Equal Opportunity Employer and does not discriminate on the basis of race, religion, color, sex, gender identity or expression, sexual orientation, age, disability, national origin, veteran status, or any other basis covered by appropriate law. Research suggests that qualified women, Black, Indigenous, and Persons of Color (BIPOC) may self-select out of opportunities if they don't meet 100% of the job requirements. We encourage individuals who believe they have the skills necessary to thrive to apply for this role. Job: Medical ServicesOrganization: Exec Office Of Health and Human Services Title: Nurse Reviewer Location: Massachusetts-Westborough - 167 Lyman Street Requisition ID: 250006IC
