Specialist - Medical, NP/PA (Workers Compensation)

Description & Requirements

Maximus is currently hiring for Specialist - Medical, NP/PA to join our team.

This is a remote opportunity and contingent upon award of contract.

The Specialist will be responsible for providing independent medical reviews for prior authorization requests for relating to Workers' Compensation benefits (WC), Disability benefits (DB), Paid Family Leave (PFL) benefits, Volunteer Firefighters' benefits, and Volunteer Ambulance Workers' benefits.



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*Please note that this position is contingent upon contract award

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Essential Duties and Responsibilities:

- Review assessments to determine if the correct conclusion for eligibility of services was reached by the nurse assessor.

- Collect data related to assessments and assessment outcomes.

- Examine each case for completeness, accuracy and consistency.

- Analyze UAS recommended scores in relation to nurse assessor determinations.

- Conduct scheduled home visits with the nurse assessor.

- Examines data for outliers and researches such cases.

- Develop/complete reports that track and trend activities/outcomes.

- Act as an advisor to UAS staff on all QA and compliance issues related to the UAS project.

- Attend Fair Hearing cases and prepare case packets, as required.

- Perform other duties as may be assigned by management.

- Review and provide independent medical reviews for prior authorization requests for relating to Workers' Compensation benefits (WC), Disability benefits (DB), Paid Family Leave (PFL) benefits, Volunteer Firefighters' benefits, and Volunteer Ambulance Workers' benefits.

- Evaluate Level 3 prior authorization requests (PARs) for medical services and goods including but not limited to all PAR types (Medication, Confirmation, Variance, Special Services, Durable Medical Equipment), all New York State Workers' Compensation Medical Treatment Guidelines and Drug Formulary criteria for all medical services, medications, medical devices contemplated therein, or requests for variances for medical treatment not addressed or recommended.

- Review all documentation submitted with the PAR, including the Level I and Level II responses.

- Review all information in the electronic case folder which is relevant and necessary for proper review of the request, in accordance with the previously provided instructions and training.

- Render medical/clinical determinations based on professional experience that is clear, professional and grammatically correct.

- Audit complex determinations for other clinical reviewers utilizing clinical expertise, medical records, New York State Workers' Compensation Medical Treatment Guidelines and Drug Formulary criteria.

- Conduct appropriate training to reviewers in using and applying the New York State Workers' Compensation Medical Treatment Guidelines and Drug Formulary criteria.

- Ability to perform comfortably in a fast-paced, production and deadline-oriented work environment.

- Provide written clinical rationales for ...