Public Consulting Group, Inc. (PCG) is a leading public sector solutions implementation and operations improvement firm that partners with health, education, and human services agencies to improve lives. Founded in 1986 and headquartered in Boston, Massachusetts, PCG has over 2,500 professionals in more than 60 offices worldwide. PCG’s Health practice offers in-depth programmatic knowledge and regulatory expertise to help state and municipal health agencies respond to regulatory change, improve access to health care, maximize program revenue, improve business processes, and achieve regulatory compliance. Using industry best practices, PCG’s Health team helps organizations deliver quality services with constrained resources to promote improved client outcomes. To learn more, visit http://www.publicconsultinggroup.com/health/.
- Performs prior authorization, concurrent and retrospective reviews
- Use clinical documentation and clinical review criteria to make determinations regarding qualifying health care costs
- Accurately records all review determinations and supporting documentation
- Contacts providers and members according to established timeframes
- Identifies and refers cases that do not meet established clinical or other criteria to the Case Management Supervisor
- Identifies and communicates quality issues to the Case Management Supervisor
- Communicates information to other team members
- Utilizes knowledge of community resources and the member’s benefit structure
- Interacts with providers, vendors, and facilities in a professional and respectful manner
- Recognizes quality of care issues and escalates the issues appropriately
- Understand and facilitate the Appeals and Grievances process
- Assists members with the coordination of services from various settings as appropriate
- Performs other duties as assigned
- Possesses effective verbal/written communication skills, especially via phone, with the ability to interact with various levels of personnel.
- Able to work in a fast-paced environment, demonstrate excellent problem solving, critical thinking, and organizational skills.
- Performs multiple tasks efficiently and accurately, have exceptional attention to detail and perform consistent work product
- Self-motivated, self-directed, team oriented, and responsible, with a positive attitude and a proactive style
- Possesses the ability to operate in a highly variable work environment.
- Presents a courteous and competent demeanor to our clients and teammates.
- Active and unrestricted LPN license
- Excellent customer service skills
- Strong computer skills
- Ability to easily navigate through website research.
Education: Degree from an accredited School of Nursing, Associate Degree required at a minimum, Bachelor’s preferred
Experience: Minimum of 2 years of direct clinical nursing experience
Minimum of 2 years of experience with medical management activities in a managed care environment, Medicaid or hospital utilization management
Certification: NY licensure is required for this role