Job description

• Conducts decision review for services requiring prior authorization in DME, leveraging technology, guidelines and resources as available.
• Processes orders for supplies, equipment and nutritional supplements based on referrals from the interdisciplinary team and submits referrals for authorization by MassHealth; leverages preferred providers and clearly notes rationale for use of non-preferred providers if/when used.
• Serves as subject matter expert in DME within CCA's iCMP PLUS Program.
• Assures proper, accurate and timely documentation in the medical record.
• Works closely with the interdisciplinary team and escalations with the Director of Clinical Operations and Client Programs as well as Clinical Management to determine next steps for DME requests, including denials following identified Standard Operating Procedures (SOP).
• Communicates status of DME, HHA and PCA services and orders in the medical record to facilitate communication between the interdisciplinary team and LPN
• Assesses need for additional structured clinical data for completion of service request.
• Handles all requests timely and accurately, adhering to performance and operational measures.
• Follows department and organizational policies and procedures as well as adheres to all applicable regulatory, contractual and compliance requirements.
• Performs all activities with closed loop processes.
• Conducts follow-up telephone calls with patients to ensure satisfaction with equipment purchases/modification and track on spreadsheet. Bring concerns to supervisor as necessary
• Maintains appropriate written and oral communication on a timely basis, completing documentation within 48 hours and returning non-urgent calls within 48 hours.
• Identify gaps in care, barriers to care and unmet patient needs.
• Coordinate with the Care Partner along with the PCP and iCMP Plus inter-professional care team to identify areas of opportunity, as well as defined resources.
• Provide input to patients care team on key care management/care coordination decisions.
• Support efforts to decrease hospital readmissions and high emergency department use.
• Participate in weekly Interprofessional Care Team meetings.
• Ensures appropriate documentation of all activities within EPIC system
• Provides consultation and support to other members of the iCMP Plus Care Team.
• Other related duties may be assigned.
• Actively participates in the evaluation of own performance and progress
• Participates in on-going education and training to improve skills
• Assists management with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects.
• Participates in committees and workgroups that promote clinical excellence.
• Minimum Education Required -- High School Diploma, GED or equivalent experience
• Preferred Education-- Associate's Degree
• Minimum Years' Experience Required: High School Diploma with 2 years' experience in community-based care
• Must hold current LPN to practice in Massachusetts
• Preferred Years' Experience: Associates Degree with 3+ years of minimum experience working in outreach or in the community with members who have high behavioral health needs and high medical complexity.
• Preferred Training and Certification(s): Current CPR Certification
• Excellent written and verbal communication skills.
• Working knowledge of Microsoft Office applications
• Excellent organizational skills.
• Ability to utilize an Electronic Medical Record
• Ability to use on-line training platforms
• Demonstrated understanding of Mass health benefits
• Ability to review welcome packets and obtain consent forms
• Demonstrated understanding of LTSS

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