Job Description Summary :
The RN Reviewer conducts telephonic review and electronic prior authorization for Inpatient Prior Authorization Certification Evaluation Review (PACER) services, select DME/MS and VDCU admissions, and continued stay reviews for the Michigan Department of Health and Human Services (MDHHS) Fee-for-Service (FFS) Medicaid and Children’s Special Health Care Services (CSHCS) beneficiaries. Additionally, the RN Reviewer performs eligibility and quality reviews to verify provider compliance with Medicaid Policy and Guidelines as outlined in the Provider manuals and Bulletins, and to determine appropriateness of Medicaid coverage for all of the above services utilizing current standards of practice, the Michigan State Plan, and Federal Regulations. The RN Reviewer reports to the RN Program Manager.
ESSENTIAL FUNCTIONS:
* Conduct prior authorization and continued stay reviews in accordance with all applicable MDHHS policy and procedures and contractual requirements.
* Apply Medicaid-approved Severity of Illness/Intensity of Service (SI/IS) criteria and clinical judgment regarding medical necessity, appropriateness of setting and quality that conforms to acceptable standards of medical practice
* Complete within the respective timeline specified by Ascend, adhering to quality benchmarks and contractual specifications, utilizing computer database system
* Must work within a tight turnaround time assuring contract compliance
* Completes other job duties as assigned or necessary
JOB REQUIREMENTS
Knowledge, Skills & Abilities
* Perform all job duties in compliance with Person First standards, HIPAA guidelines, and company confidentiality policies and procedures
* Self-directed in setting work priorities, timelines, and goal setting
* Knowledgeable in McKesson InterQual® criteria, industry best practices, and state policy and procedures
* Ability to multitask effectively while performing job duties, including ability to prioritize tasks and ensuring all voice mail and email messages are returned within contract standards
* Ability to work independently with minimal day-to-day supervision
* Excellent written and verbal communication skills
* Excellent interpersonal skills
* Ability to interact professionally and collegially with providers, state contract officers, and coworkers
* Intermediate skill with word processing and spreadsheet software (Microsoft Word and Excel preferred)
* Education
The job requires a Registered Nurse, with a valid license in Michigan.
Experience
* The job requires at least three (3) years of experience in health care, including utilization management and long-term services and supports in a variety of settings.
EEO Statement: Active military service members, their spouses, and veteran candidates often embody the core competencies MAXIMUS deems essential, and bring a resiliency and dependability that greatly enhances our workforce. We recognize your unique skills and experiences, and want to provide you with a career path that allows you to continue making a difference for our country. We’re proud of our connections to organizations dedicated to serving veterans and their families. If you are transitioning from military to civilian life, have prior service, are a retired veteran or a member of the National Guard or Reserves, or a spouse of an active military service member, we have challenging and rewarding career opportunities available for you. A committed and diverse workforce is our most important resource. MAXIMUS is an Affirmative Action/Equal Opportunity Employer. MAXIMUS provides equal employment opportunities to all qualified applicants without regard to race, color, religion, , orientation, gender identity, national origin, protected veteran status or disabled status.
