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Under the general direction of the NIPR Manager or designee, Clinical Reviewer Auditor is tasked with the responsibility to perform and oversee retrospective, post-payment case reviews of community-based providers who participate in MassHealth. There are approximately 20 different provider types under NIPRs scope of work, each with its own set of regulations and standards of care. The purpose of these case reviews is to detect possible fraud, waste and abuse and ensure compliance with regulations governing MassHealth providers as well as to determine whether the services were medically necessary, appropriate, and of a quality that meets professionally recognized standards.  This clinical oversight contributes to improving patient care and increasing the overall health of MassHealth members through education to the provider under review through the Notice of Findings.  The Clinical Reviewer Auditor works within specific guidelines and procedures and applies advanced technical knowledge in performing these case reviews to bring clarity into highly complex situations.

• Direct MassHealth in policy improvement and procedure initiatives.
• Act as a subject matter expert resource for OCA staff, and to external agencies as it relates to fraud, waste, abuse.
• Direct the development of policy changes based on case reviews.
• Coordinate and support the establishment of departmental policies, procedures, and objectives in conjunction with the NIPR Manager.
• Represent OCA/NIPR on cross-functional committees. Assess and evaluate the care needs of MassHealth members.
• Collaborate with MassHealths IT analytics for case analysis, including generation of ad hoc reports when necessary.
• Apply laws, regulations, plan policies and guidelines, contract provisions, coding rules, coverage rules, and industry standards for the specific provider type to information gathered during the review process.
•  Prepare and present comprehensive case analyses to stakeholders. Issue formal correspondence to providers under reviews.
•  Draft notice of findings by examining medical records against claim lines, noting issues with quality of care, medical necessity, recordkeeping, and billing. Check MassHealth regulations for compliance and include any concerns in the notice. Also, analyze utilization patterns for possible fraud, waste, and abuse. Collaborate with NIPRs Medical Director to ensure consistent reviews.
• Collaborate with state and federal agencies as needed.
• Develop Board of Hearing (BOH) presentations and participate in appeals.  
• Develop quarterly reports for MassHealth.
• Direct Provider Compliance and MassHealth Finance Units to establish provider withholds and recoupments; track and monitor recovery of provider withholds and recoupments.
• Collaborate with EHS Legal during case review process as needed for potential settlement discussion.
• Collaborate with MassHealth stakeholders throughout the NIPR process.
• Perform other similar and related duties as required or as directed.

REQUIRED QUALIFICATIONS: 

• Unrestricted, and disciplinary action free, RN, Certified Nurse Practitioner (CNP), or Physician Assistant Certified (PA-C) license to practice in the Commonwealth of Massachusetts.
• Masters degree in business administration, healthcare, nursing, or related field.
• Minimum of 10 years clinical experience.
• Very strong written and oral communication skills; able to create clear and persuasive reports understandable to non-experts.  
• Demonstrated strong interpersonal skills

PREFERRED QUALIFICATIONS:

• Certified Nurse Practitioner or PA-C.
• Understanding of healthcare industry, claims processing, E&M coding, DRGs, and internal investigative process development.
• In-depth knowledge of, and the ability to understand and apply, local, state, and federal laws and regulations.
• In-depth knowledge of, and the ability to understand and apply, MassHealth regulations including transmittal letters and contract provisions.
• Prior utilization review and/or medical coding experience.
• Prior experience with medical review, audits and prior healthcare Fraud, Waste and Abuse investigation is desirable.
• Case Management certification desirable.
• Prior experience in medical surgical, primary care, emergency room, urgent care, pediatrics, rehabilitation, home care, or other long-term services is desirable.