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General information

Job Posting Title
Specialist – Medical, NP/PA (Workers Compensation)
Date
Tuesday, April 29, 2025
City
Remote
Country
United States
Working time
Full-time

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.

***Please note that this position is contingent upon contract award***

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 Workers Compensation cases.
- Review, organize and identify all medical records provided for prior authorization requests (PAR) for assigned workers comp cases.
- Monitor timeliness of reviews to ensure applicable standards are met.
- Consistently meet production and quality standards.
- Perform special projects as assigned such as clinical research, general medical research, etc.
- Become a subject matter expert (SME) using job aides and learning tools.
- Work on special projects as assigned.
- Other duties as assigned by management.
Minimum Requirements

- Current Nurse Practitioner (NP) or Physician Assistant (PA) license valid in the state of practice is required

- Bachelor's degree with 3+ years of experience.

- May have additional training or education in area of specialization.

- Develop solutions to a variety of problems of moderate scope & complexity.

- General application of concepts & principles.

- Contribute to the completion of organizational projects & goals.

- Frequent use and general knowledge of industry practices, techniques, and standards.

- Apply knowledge and skills to complete a wide range of tasks.

- Communicate on complex or sensitive issues or draft responses for supervisor or manager.

- Experience in New York state workers compensation program, including applying New York State Workers’ Compensation Medical Treatment Guidelines and Drug Formulary criteria required.
- Possess ample medical knowledge and experience with medical terminology, ICD-9/10 Codes, Current Procedure Terminology Codes (CPT) codes.

Preferred Skills and Qualifications:
- Healthcare Common Procedure Coding System (HCPCS) coding practices.
- Medicare coverage guidelines.
- Anatomy, physiology, and pharmacology.
- Clinical practice guidelines.
- Utilization review standards and practices.
- State-specific workers’ compensation guidelines and pricing structure.
- Health Insurance Portability and Accountability Act (HIPAA) and related healthcare confidentiality regulations.

Please note: For this position Maximus will provide equipment to use.

Home Office Requirements:
- Internet speed of 20mbps or higher required / 50 Mpbs for shared internet connectivity (you can test this by going to www.speedtest.net)
- Minimum 5mpbs upload speed
- Connectivity to the internet via either Wi-Fi or Category 5 or 6 ethernet patch cable to the home router
- Private work area and adequate power source
- Must currently and permanently reside in the Continental US


EEO Statement
Maximus is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, age, national origin, disability, veteran status, genetic information and other legally protected characteristics.
Pay Transparency
Maximus compensation is based on various factors including but not limited to job location, a candidate's education, training, experience, expected quality and quantity of work, required travel (if any), external market and internal value analysis including seniority and merit systems, as well as internal pay alignment. Annual salary is just one component of Maximus's total compensation package. Other rewards may include short- and long-term incentives as well as program-specific awards. Additionally, Maximus provides a variety of benefits to employees, including health insurance coverage, life and disability insurance, a retirement savings plan, paid holidays and paid time off. Compensation ranges may differ based on contract value but will be commensurate with job duties and relevant work experience. An applicant's salary history will not be used in determining compensation. Maximus will comply with regulatory minimum wage rates and exempt salary thresholds in all instances.
Minimum Salary
$
90,000.00
Maximum Salary
$
110,000.00