Sr. Coordinator – Clinical Ops, LPN

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 Sr. Coordinator – Clinical Ops, LPN 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 documentation and/or assessments and applying clinical criteria to complete determinations, approvals or recommendations. Determine need for and obtain any additional information required to complete actions. Determine when escalation or consultation is required with supervisor, physician or related medical or related clinical discipline. Complete reports or documentation in accordance with contract requirements. Performs other related duties as assigned. 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%.