Description & Requirements

Maximus is currently hiring for a Specialist - Nursing, RN to join our QIC Part A West team. This is a remote opportunity. The Specialist is responsible for completing clinical reviews for Medicare Part A West. These will be second-level appeals that require review of medical documents to determine, using Medicare coverage criteria, how a service should be paid.

This is a production-based position.

Essential Duties and Responsibilities:

- Responsible for reviewing favorable and partially favorable determinations in accordance with applicable regulations.

- Render medical necessity determinations for cases assigned.

- Resolve all other technical issues within reconsideration assigned.

- Review cases or sites assigned to determine and summarize facts and assess any issues identified.
- Perform other special projects not related to a specific case such as general legal research, general medical research, drafting proposal sections, or acting as a liaison for a specific project, when necessary.

- Perform other duties as assigned by management.

- Reports directly to QIC Adjudication Manager.
- Perform technical appeal review under the direction of the professional clinical reviewers and the QIC Adjudication Manager.

- Review ISO compliant work instruction, process documents, and medical review templates as directed by QIC Adjudication Manager.

- Assist other projects or departments as directed by QIC Adjudication Manager.

- Understand workflow process and offer suggestions for improvement.

- Perform other duties as assigned by QIC Adjudication Manager.

- Must meet or exceed daily productivity requirements.

- Must maintain a QA score of 95 - 100%.

Minimum Requirements

- Bachelor's degree required

- Active RN license required.

- Minimum 2 years clinical experience required with RN license.

- Continuing education courses as required by state to maintain RN license.

- Ability to redirect work focus, as business need or workload volumes dictate.

- Ability to work independently in a remote setting.

- Critical thinking and analytical skills.

- Excellent written and oral communication skills.

- Strong organizational skills and attention to detail.

- Strong computer skills and knowledge of MS Office Suite, Chrome, Microsoft Edge.

- Ability to work an 8-hour schedule between the hours of 7:30am - 6:00pm EST Monday - Friday required.

Preferred Skills & Experience:
- Clinical experience in an acute or long-term care setting.

- Certification in ICD-10 billing and coding.

- Knowledge of Medicare Part A and/or Part B of A.

- Clinical training, education, or certification.

- Experience in production-based environment.

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

Home Office Requirements:

- Internet speed of 25mbps 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 Category 5 or 6 ethernet patch cable to the home router

- Private and secure work area and adequate power source

- Must currently and permanently reside in the Continental US

- Must have a smartphone which will be required to log into Maximus systems

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.

Accommodations

Maximus provides reasonable accommodations to individuals requiring assistance during any phase of the employment process due to a disability, medical condition, or physical or mental impairment. If you require assistance at any stage of the employment process-including accessing job postings, completing assessments, or participating in interviews,-please contact People Operations at applicantaccom@maximus.com .

As a leading strategic partner to governments across the globe, Maximus helps improve the delivery of public services amid complex technology, health, economic, environmental, and social challenges. With a deep understanding of program service delivery, acute insights that achieve operational excellence, and an extensive awareness of the needs of the people being served, our employees advance the critical missions of our partners. Maximus delivers innovative business process management, impactful consulting services, and technology solutions that provide improved outcomes for the public and higher levels of productivity and efficiency of government-sponsored programs.