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 NIPR’s 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.Responsibilities
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