Nurse Reviewer II-Case Mgt (Home Based with Client Visits)

POSITION SUMMARY:

ForHealth Consulting at UMass Chan Medical School is seeking a detail-oriented Nurse Reviewer II with experience caring for individuals with complex medical needs to join our Community Case Management Program. In this role, you will manage a caseload of members, ensuring they receive the long-term services and supports (LTSS) they need to thrive in the community. This position combines the flexibility of remote work with meaningful field interactions through home and site visits.

You'll play a key role on a multidisciplinary team - assessing, planning, coordinating, and authorizing care for individuals with complex medical needs, while collaborating closely with providers, state agencies, and other healthcare partners to ensure continuity and quality of care.

ESSENTIAL FUNCTIONS

Serve as the clinical case manager for an assigned caseload of members.
• Conduct on-site assessments to determine medical necessity and clinical eligibility for Community Case Management and Continuous Skilled Nursing Services.
• Authorize, coordinate, and monitor long-term care services in accordance with program guidelines.
• Prepare and maintain comprehensive service records and documentation in compliance with program and HIPAA requirements.
• Collaborate with providers, hospitals, and agencies to foster integrated care delivery.
• Review service plans and modify as needed based on member progress or changing needs.
• Participate in performance improvement initiatives and support onboarding of new clinical staff.

REQUIRED QUALIFICATIONS:

• RN licensed to practice in Massachusetts
• 5-7 years of work experience with at least 3 recent years providing direct service or case management to the pediatric, young adult, or adult medically complex population
• Ability to travel statewide to Member homes and service providers places of business
• Experience with Office Application and database
• Valid Driver's license required

• Experience with home care
• Knowledge of applicable state regulations
• Experience with prior authorization and/or eligibility determinations
• Experience with the care of medically complex individuals

Why Join Us

At ForHealth Consulting, part of UMass Chan Medical School, we are dedicated to advancing health and well-being across Massachusetts communities. You'll be part of a mission-driven organization that values collaboration, innovation, and compassion in care management.