Job Summary:
o This role reviews clinical documentation and requests submitted by individuals and/or providers to determine appropriate level of care and/or prior authorization.
Essential Duties and Responsibilities:
o Review requests for services including admission, discharges and continued stays for adherence to clinical criteria, state and federal policy, and related requirements.
o Issue approvals, denials or recommendations based on contract requirements.
o Identify need for additional clinical documentation or consultation.
o Complete documentation of activities within contract systems.
o Communicate with providers, individuals and their designees, or state workers as required.
o Performs other related duties as assigned.
Required Skills/Abilities:
o Preferred knowledge may include community support programs, long-term care assessment and level of care in medical, behavioral health or related programs
o Knowledge and understanding of medical and/or behavioral health diagnoses and prescribed medications
o Ability to collect data, define problems, establish facts, and draw valid conclusions
o Excellent written and verbal communication skills
o Excellent interpersonal and customer service skills
o Proficient in Microsoft Office Suite
o Excellent organizational skills and attention to detail
o Ability to work in a fast-paced environment
o Ability to work independently and meet timelines
Education and Experience:
o Education and licensure requirements are based on program contract requirements and are outlined in job posting
o High School Degree or equivalent required
o Minimum 2 years of clinical experience required
Candidates must hold one of the following licenses in Louisiana:
LPC: Licensed Professional Counselor
LMFT: Licensed Marriage and Family Therapist
LMSW: Licensed Master Social Worker
LCSW: Licensed Clinical Social Worker
Plus a minimum of 2 years experience in mental health diagnosis and assessment.
Essential Duties and Responsibilities:
- Responsible for pre-admission and concurrent reviews for admissions and continued placement in Medicaid certified nursing facilities, utilizing federal and State’s criteria
- Review and communicate all information with providers, utilizing computer database system for determining nursing facility placement appropriateness
- Utilize both referral screens and medical records review to make determinations
- Develop and document a clinical rationale supporting the review decision as the final step in the review process. Must work within a tight turnaround time assuring contract compliance
- Complete other job duties as assigned or necessary
Minimum Requirements:
- Graduation from an accredited school of nursing, with current RN or LPN, or a MSW, or related license, in good standing, as dictated by the client contract
- At least four (4) years of experience working with individuals with a mental health diagnosis and/or intellectual disability, with the primary focus on behavioral health, as dictated by the client contract, plus one (1) year of quality review experience. In addition, candidates must have a minimum of two (2) years of medical experience with a strong understanding of rehabilitation potential, based on diagnosis, age, disease process and chronicity also as dictated by the client contract
- 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 and Excel preferred)
- Ability to work with dual computer monitors, research information on the internet, utilize company resources/ tools stored on company sites
MAXIMUS IntroductionSince 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 programs. Maximus 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 programs. With 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 Kingdom. For more information, visit
As a large employer and Federal contractor, Maximus is subject to various vaccine mandates across our lines of business. Maximus is committed to complying with any applicable vaccine mandates. The specific vaccine requirements for this position will be outlined throughout the selection process. Individuals who believe they may qualify for a medical or religious accommodation will have the opportunity to apply for an accommodation following an offer of employment. 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, sex, sexual orientation, gender identity, national origin, protected veteran status or disabled status.