Job details
Job type part-time
Full job description
Job description summary:
Perform document-based and telephonic utilization review for contracted services; screening for diagnosis or suspicion of serious mental illness and or intellectual disability, and medical necessity for short or long term nursing facility placement.
Job summary:
Essential duties and responsibilities:
Make outbound phone calls to nursing facilities to determine eligibility for pre-admission, concurrent reviews for admissions, continued placement in medicaid certified nursing facilities, utilizing federal and state’s criteria
Schedule document-based quality reviews that adhere to state-directed clinical criteria for determining medical need
Reviews and communicates all information with providers, utilizing computer database system for determining nursing facility placement appropriatenessUtilizes both referral screens and medical records review to make determinations
Responsible for pulling data from multiple systems, performing data analysis, and then initiating robotic process automation jobs to move data between systems
Review rejected data and troubleshoot the cause, and correct any source files to prevent future occurrences of rejects
Perform data analysis functions to ensure integrity of data in systems used by the programSome intermediate to advanced excel based skills is necessary to reconcile data between systems
Monitor multiple work queues daily to ensure cases move quickly through each process stageIf data errors or human errors are preventing the case from moving forward, determine and resolve the problem
Assist with monthly billing and quarterly reporting processes which includes extracting data from two systems, performing analysis to consolidate data found in both systems, and perform manual research when data has not been properly entered
Provide feedback to program manager of the types of errors and root causes
Review submitted evaluations for potential duplicatesMake outbound calls to facilities to determine cause
Track high volume and/or difficult to reach facilitiesPull queries to identify which facilities have caused the turn-around-time contractual standard to be missed, so data can be reported to the state
Complete other job duties as assigned or necessary
Minimum requirements:
High school diploma or equivalent with 4+ years of professional experience working with persons with serious mental illness and/or intellectual disability, or aa degree with 2+ years of professional experience working with persons with serious mental illness and/or intellectual disability
Bachelor’s degree in human services related field preferred
Perform all job duties in compliance with person first standards, hipaa guidelines, and company confidentiality policies and procedures
Excellent knowledge of diverse cultures and issues, with the ability to incorporate special needs into utilization review decisions
Working knowledge and understanding of behavioral health diagnoses, psychotropic medications, medical diagnoses and prescribed medications
Excellent ability to multitask while effectively performing job duties, which include prioritizing tasks; ensure all voice mail and email messages are monitored and responded to within 2 hours of receipt
Ability to work independently, as well as within a team while exhibiting excellent interpersonal skills
Excellent written and verbal communication skills
Ability to interact professionally with providers (hospital & nursing home staff, physicians, community service workers, etc.), state contract officers, and coworkers while seeking or providing information
Ability to collect data, define problems, establish facts, and draw valid conclusions for supporting a superior written rationale for review determination
Excellent computer skills with experience in word processing, email and spreadsheets (microsoft word, outlook preferred and intermediate (to advanced) excel skills required); ability to work with dual computer monitors, research information on the internet, utilize company resources/ tools stored on company sites
Maximus introduction: since 1975, maximus has operated under its founding mission of helping government serve the people, enabling citizens around the globe to successfully engage with their governments at all levels and across a variety of health and human services programsMaximus delivers innovative business process management and technology solutions that contribute to improved outcomes for citizens and higher levels of productivity, accuracy, accountability and efficiency of government-sponsored programsWith more than 30,000 employees worldwide, maximus is a proud partner to government agencies in the united states, australia, canada, saudi arabia, singapore and the united kingdomFor more information, visit https://www.maximus.comEeo statement: 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 workforceWe 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 countryWe’re proud of our connections to organizations dedicated to serving veterans and their familiesIf 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 youA committed and diverse workforce is our most important resourceMaximus is an affirmative action/equal opportunity employerMaximus provides equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status or disabled status.
