Registered Nurse - Authorization Review

For more information about the position, including the complete job description and the compensation information, click Apply Now.

Position Duties: 

• Manage medical Prior Authorizations (PA) as assigned by the PA supervisor, utilizing PA software tools;
• Review and authorize provider requests for the following services in the MaineCare Benefits Manual (MBM): Section 97, Private Duty Nursing and Personal Care Services, Sec. 85, Physical Therapy, Sec. 68, Occupational Therapy, Sec. 109,Speech Therapy, Sec. 1.14-2 Out-of-State Services, Sec. 94, Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services, and other services, assigned;
• Perform day-to-day activities required for PA processing and follow defined business rules and policies, including timeliness requirements;
• Resolve escalated complex PA reviews/dispositions based on business rules and workflow policies;
• Work with the Prior Authorization unit staff members to monitor work queues and complete assigned tasks;
• Conduct regular quality assurance reviews of decided PAs;
• Collaborate with other OMS units to resolve claims issues that involve PAs;
• Respond to questions and concerns from interested parties regarding PA criteria and processes;
• Be responsible for communications to providers, MaineCare members, and others via phone, fax, and mail;
• Perform basic research on medical conditions, medical services, and health care providers; and
• Perform other duties and responsibilities as may be assigned.

Knowledge and Certification Requirements:

• Knowledge of the principles and methods of professional nursing practice.

• Knowledge of current standards of care and practices relating to services provided by health care facilities, agencies, and practitioners.
• Ability to plan, organize, and direct the work of others.
• Ability to maintain objectivity and professionalism during unusual and stressful circumstances.
• Ability to communicate effectively
• Ability to write clearly and effectively

 

These may be acquired on the job and are needed to perform the work assigned:

• Knowledge of state and federal regulations relative to the qualifications of health care professionals and paraprofessionals.
• Knowledge of community organizations and resources.
• Knowledge of state licensing and federal certification regulations for health care providers.
• Knowledge of federal and state accreditation commissions and standards.
• Knowledge of Department policies and procedures.
• Knowledge of the Maine Medical Assistance Manual.
• Ability to interpret and apply federal and state rules and regulations.
• Ability to provide technical assistance.
• Ability to develop and implement corrective actions.

 

Minimum Qualifications:

• Registered Nurse and three (3) years of progressively responsible experience in the field of nursing and/or in the delivery of health care services.
• Licensing Requirements: Licensed as a Registered Professional Nurse or Licensed Practical Nurse (LPN) in the State of Maine as issued by the State Board of Nursing. RN is preferred, however, an LPN is acceptable if a RN is not available.

 

Knowledge and Certification Requirements:

• Knowledge of the principles and methods of professional nursing practice.

• Knowledge of current standards of care and practices relating to services provided by health care facilities, agencies, and practitioners.
• Ability to plan, organize, and direct the work of others.
• Ability to maintain objectivity and professionalism during unusual and stressful circumstances.
• Ability to communicate effectively
• Ability to write clearly and effectively

 

These may be acquired on the job and are needed to perform the work assigned:

• Knowledge of state and federal regulations relative to the qualifications of health care professionals and paraprofessionals.
• Knowledge of community organizations and resources.
• Knowledge of state licensing and federal certification regulations for health care providers.
• Knowledge of federal and state accreditation commissions and standards.
• Knowledge of Department policies and procedures.
• Knowledge of the Maine Medical Assistance Manual.
• Ability to interpret and apply federal and state rules and regulations.
• Ability to provide technical assistance.
• Ability to develop and implement corrective actions.

 

Minimum Qualifications:

• Registered Nurse and three (3) years of progressively responsible experience in the field of nursing and/or in the delivery of health care services.
• Licensing Requirements: Licensed as a Registered Professional Nurse or Licensed Practical Nurse (LPN) in the State of Maine as issued by the State Board of Nursing. RN is preferred, however, an LPN is acceptable if a RN is not available.

Registered Nurse - Health Services Consultant

Authorization Review – Office of MaineCare Services in Augusta, ME

This role will be Fulltime and will require  40 work hours per week.

 

This role must be located in the State of Maine.

 

Staffing Solutions Organization LLC (SSO), an affiliate of Public Consulting Group LLC (PCG), is focused on delighting clients with world-class managed staffing and talent consulting services. SSO is committed to a diverse workforce, which is a reflection of our clients and the people they serve.

 

Public Consulting Group is an Equal Opportunity Employer dedicated to celebrating diversity and intentionally creating a culture of inclusion. We believe that we work best when our employees feel empowered and accepted, and that starts by honoring each of our unique life experiences. At PCG, all aspects of employment regarding recruitment, hiring, training, promotion, compensation, benefits, transfers, layoffs, return from layoff, company-sponsored training, education, and social and recreational programs are based on merit, business needs, job requirements, and individual qualifications. We do not discriminate on the basis of race, color, religion or belief, national, social, or ethnic origin, sex, gender identity and/or expression, age, physical, mental, or sensory disability, sexual orientation, marital, civil union, or domestic partnership status, past or present military service, citizenship status, family medical history or genetic information, family or parental status, or any other status protected under federal, state, or local law. PCG will not tolerate discrimination or harassment based on any of these characteristics. PCG believes in health, equality, and prosperity for everyone so we can succeed in changing the ways the public sector, including health, education, technology and human services industries, work.