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

Role Description As a Paediatric Healthcare Assistant at Komplex Care, you’ll be providing care and support to a client, whose individual needs includes: - PEG - Brain Injury - Developmental Needs - Epilepsy - Palliative Care - Personal Care - Medication Administration Qualifications - Level 2 or 3 NVQ/QCF in health care is desirable. Requirements - Existing work authorisation for the UK. Benefits - Pension Scheme for long-term security. - 24/7 GP access for you, your partner, and children (up to 18). - Free mental health support for you, your partner, and children (up to 18). - Life insurance for peace of mind when it matters most. - Home life advice line for everyday guidance. - Career development opportunities. - Wellbeing videos and guided meditations. - Earn points for staying active. - Vouchers for Amazon, Tesco, Nike and more. - Up to 33% off gym memberships. - Employee of the Month recognition with a £50 voucher.