Specialist - Nursing, RN

We’re moving people forward by providing transformative technology services, digitally enabled customer experiences, and clinical health services that change lives. Our employees share an authentic desire to make vital services available to the public and support the missions of our customers.

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.

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%.