• Perform medical claim reviews for claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations. • Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. • Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. • Monitors process’s timeliness in accordance with contractor standards. • Document medical rationale to justify payment or denial of services and/or supplies. • Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. • Participate in quality control activities in support of the corporate and team-based objectives. • Provide guidance, direction, and input as needed to LPN team members. • Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback. • Assists with special projects and specialty duties/responsibilities as assigned by management.

• Perform ongoing clinical data review to ensure data quality, consistency, and completeness • Identify discrepancies and raise/resolve queries in EDC systems • Review patient data including eligibility, medical history, treatment, safety data, and outcomes • Contribute to and follow the Data Review Plan (DRP) • Cross-check data across multiple sources (e.g., EDC, labs, safety databases) • Support data cleaning activities ahead of interim analyses and database lock • Collaborate with Clinical, Data Management, and Operations teams to resolve data issues • Monitor site data entry performance and escalate risks or delays • Participate in study meetings and provide status updates on data review activities • Ensure compliance with GCP, protocols, and regulatory requirements

Title: Nurse Reviewer II-LOC (2026-49863) - Job Number: 2026-49863 - Category: Healthcare - Location: Westborough, MA - Shift: Day - Exempt/Non-Exempt: Exempt - Business Unit: ForHealth Consulting - Department: ForHealth Consulting - Community Service - W401950 - Job Type: Full-Time - Union Code: Non Union Position -W60- Non Unit Professional - Num. Openings: 1 - Work Location: 100% Remote - Salary Minimum: USD $80,000.00/Yr. - Salary Maximum: USD $95,000.00/Yr. Job Description: General Summary: Under the general supervision of the Associate Director, or designee, the Nurse Reviewer II is responsible for completing in-person assessments and reviewing supporting documentation to determine clinical eligibility for individuals who are residing in the community receiving services through the Family Assistance Pathway. Additionally, the Nurse Reviewer II provides education to MassHealth members on the next steps in the MassHealth eligibility process. Responsibilities: - Provide outreach to members to schedule visits in a timely manner. - Conduct on-site assessments of members medical, functional, psychosocial, and supportive needs to determine clinical eligibility completing the MDS-HC assessment and associated forms. - 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 members needs, without bias. - Review and document all relevant information into data system applications in accordance with program guidelines and regulations. - Maintain individual records documenting all member encounters and contacts. - Participate in public relations efforts, attending conferences and meetings as needed. - Maintain positive working relationships with members, and relevant formal/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. 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 Preferred Qualifications: - Experience with disabled or long term care populations - Experience completing MDS or MDS-HC assessments - Experience in one of the following areas: Long-Term Care, Home Care, Rehab, and/or Disabilities - Bilingual in Spanish Posting Disclaimer: This job posting outlines the primary responsibilities and qualifications for the role but is not intended to be an exhaustive list. Duties and expectations may evolve in response to the needs of the department and the broader institution. In alignment with our commitment to pay transparency, the base salary range for this position is listed above (exclusive of benefits and retirement). At UMass Chan Medical School, final base salary offers are determined based on a combination of factors, including your skills, education, and relevant experience. We also consider internal equity to ensure fair and consistent compensation across our teams. Please note that the range provided reflects the full base salary range for this position. Offers are typically made within the midrange to allow for future growth and development within the role. In addition to base pay, UMass Chan offers a comprehensive Total Rewards package, which includes paid time off, medical, dental, and vision coverage, and participation in a 401(a)-retirement plan, with the option to contribute to a voluntary 403(b) plan. UMass Chan welcomes all qualified applicants and complies with all state and federal anti-discrimination laws.

• Lead senior-level clinical review of complex dermatology cases • Provide structured clinical reasoning and guideline-aligned commentary • Resolve clinical disagreements across reviewer groups • Contribute to development of evaluation frameworks and methodologies • Support AI model evaluation through expert advisory sessions • Provide subspecialty input on complex or ambiguous cases • Ensure high-quality, clinically defensible documentation • Collaborate with peer reviewers and research stakeholders • Maintain adherence to clinical and project protocols