Role Description This is an entry level position responsible for processing all release of information (ROI), specifically medical record requests, in a timely and efficient manner ensuring accuracy and providing customers with the highest quality product and customer service. Associate must at all times safeguard and protect the patient’s right to privacy by ensuring that only authorized individuals have access to the patient’s medical information and that all releases of information are in compliance with the request, authorization, company policy and HIPAA regulations. - Full-Time: Monday - Friday, 8:00 am - 4:30 pm EST - Location: Remote - Comfortable working in a high-volume production environment. - Processing medical record requests by taking calls from patients, insurance companies and attorneys to provide medical record status. - Documenting information in multiple platforms using two computer monitors. - Proficient in Microsoft Office (including Word and Excel). Qualifications - High School Diploma or GED. - Ability to commute between locations as needed. - Able to work overtime during peak seasons when required. - Basic computer proficiency. - Comfortable utilizing phones, fax machine, printers, and other general office equipment on a regular basis. - Professional verbal and written communication skills in the English language. - Detail and quality oriented as it relates to accurate and compliant information for medical records. - Strong data entry skills. - Must be able to work with minimum supervision responding to changing priorities and role needs. - Ability to organize and manage multiple tasks. - Able to respond to requests in a fast-paced environment. Requirements - Receive and process requests for patient health information in accordance with Company and Facility policies and procedures. - Maintain confidentiality and security with all privileged information. - Maintain working knowledge of Company and facility software. - Adhere to the Company's and Customer facilities Code of Conduct and policies. - Inform manager of work, site difficulties, and/or fluctuating volumes. - Assist with additional work duties or responsibilities as evident or required. - Consistent application of medical privacy regulations to guard against unauthorized disclosure. - Responsible for managing patient health records. - Responsible for safeguarding patient records and ensuring compliance with HIPAA standards. - Prepares new patient charts, gathering documents and information from paper sources and/or electronic health record. - Ensures medical records are assembled in standard order and are accurate and complete. - Creates digital images of paperwork to be stored in the electronic medical record. - Responds to requests for patient records, both within the facility and by external sources, retrieving them and transmitting them appropriately. - Answering of inbound/outbound calls. - May assist with patient walk-ins. - May assist with administrative duties such as handling faxes, opening mail, and data entry. - Must meet productivity expectations as outlined at specific site. - May schedule pick-ups. - Other duties as assigned. Benefits - Comprehensive onsite/virtual training program followed by job shadowing with an assigned mentor. - Company equipment will be provided to you (including computer, monitor, virtual phone, etc.). - Full Benefits: PTO, Health, Vision, and Dental Insurance and 401k Savings Plan and Tuition Assistance.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Under the general supervision of the Associate Director, or designee, the Nurse Reviewer II is responsible for completing in-person assessments and reviewing medical records to determine clinical eligibility for individuals who are residing in a nursing facility, chronic disease, or rehabilitation hospital who would like to return to the community and receive supports and services through the ABI and MFP Home and Community Based Waivers. Additionally, the Nurse Reviewer II completes annual or interval in-person assessments by reviewing medical records, assessing community needs and risks, and provides resource support for program participants/applicants. This position ensures that eligible individuals can be safely served in accordance with relevant program/waiver guidelines and regulations. Qualifications - Bachelor’s Level Degree in Nursing - RN with current licensure to practice in Massachusetts - 5-7 years of related work experience - Knowledge of applicable state regulations - Ability to travel statewide - Experience with Office Application and database Requirements - Contribute as an active member of a multi/inter-disciplinary team to assess, plan, organize, review and evaluate clinical eligibility. - Conduct on-site assessments of applicants’/participants’ medical, functional, psychosocial, and supportive needs to determine community, whether risks can be mitigated, and mitigation strategies within the terms of the ABI/MFP Waiver. - Review and document all relevant information into data system applications in accordance with program guidelines and regulations. - Utilizes critical thinking skills to complete written, clinically based comprehensive assessments that accurately depict the applicants’/participants’ holistic needs, without bias. - Contact providers, state agency offices, and applicants/participants, and collateral support to obtain information and records needed to conduct a comprehensive clinical review of the case and final determination. - Maintain individual records documenting all applicant/participant encounters and contacts. - Foster and promote continuity of care and cooperative partnerships by liaising with health care providers, acute care hospitals, long term care facilities and other programs/organizations involved in the provision of services. - Participate in public relations efforts, attending conferences and meetings as needed. - Maintain positive working relationships with applicants/participants, and relevant informal supports, provider organizations, program consultants and state agencies. - Maintain the confidentiality of all business documents and correspondence per UMass Chan Medical School (UMass Chan)/ForHealth Consulting procedures and HIPAA regulations. - Participate in performance improvement initiatives and demonstrate the use of quality improvement in daily operations. - Comply with established departmental policies, procedures and objectives. - Comply with all health, safety and program regulations and requirements. - Participates in training and onboarding of new clinical staff. - State-wide travel is required for this position. - Perform other duties as required. Benefits - Experience with disabled or long term care populations - Experience in one of the following areas: Long-Term Care, Home Care, Rehab, Brain Injury, Mental Health, Substance Abuse and/or Disabilities. - Remote/desk work with statewide travel required - Concentration to Northeastern MA

• Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals • Documents decisions using indicated protocol sets or clinical guidelines • Provides support and review of medical claims and utilization practices • May provide any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge payment determination • Monitors process's timeliness in accordance with contractor standards • Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines • Utilizes allocated resources to back up review determination • Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process • May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs • Performs screenings/assessments and determines risk via telephone • Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services • Provides education to members and their families/caregivers • Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each • Conducts research necessary to make thorough/accurate basis for each determination made • Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines • Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations • Participates in quality control activities in support of the corporate and team-based objectives

• Conducting benefit coverage reviews and utilization management according to applicable regulatory guidelines and Enterprise contract requirements • Daily interactions with UM Support staff and providers to ensure clinical information and support are available and applicable to the review process • Appropriate prioritization of authorization requests • Review of all assigned prior authorization requests including but not limited to inpatient admissions, specialty referrals, outpatient procedures, VNA or outpatient therapies • Concurrent review of Behavior Health Services