Sr Consultant, Medical Ops (remote)
Description & Requirements
Maximus is looking for a Sr.
Consultant - Clinical Ops with QIC Experience.
This is a fully remote role.
The Sr.
Consultant - Clinical Ops serves as the point of contract (POC) for allocating work and providing education, guidance and training to team members for DMEPOS appeal adjudication.
Essential Duties and Responsibilities:
- Responsible for reviewing favorable, and partially favorable, determinations in accordance with applicable regulations.
- Render medical necessity determinations for Medicare State East cases assigned.
- Resolve all other technical issues within Medicare reconsideration assigned.
- Review cases to determine and summarize facts of each case assigned and assess issues involved in the case.
- May 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.
- Be the Subject Matter Expert (SME) for project.
- Perform other duties as assigned by management.
Essential Duties and Responsibilities:
* Performs adjudication on all DMEPOS appeal case types.
* Responsible for reviewing documentation and applying Medicare coverage criteria to adjudicate clinical DMEPOS appeals following project guidance.
* Review, organize and identify all medical records provided for DME cases.
* Provide written clinical rationales for DMEPOS cases.
* Monitor timeliness of reviews to ensure applicable standards are met.
* Consistently meet production and quality standards.
* Perform other related duties and/or special projects as assigned.
* Become a subject matter expert (SME) using job aides and learning tools.
* Work on assignments that are moderately difficult, requiring judgement in resolving issues.
* Understand implications of work and make recommendations for solutions.
* Communicate on complex or sensitive issues or draft such responses for manager.
* Works on a variety of assignments requiring considerable judgement and initiative.
* As a skilled and experienced specialist, completes tasks in resourceful and effective ways.
* Able to draft or modify training materials and procedural documentation accurately.
* Skilled in handling challenging communications.
* Act independently to determine methods and procedures on new assignments.
* Perform quality assurance on work of others in team.
Position Requirements:
* Excellent verbal and written communication skills
* Proven organization and time management skills
* Leadership and teaching skills to educate others
* People skills
* Problem solving and analytical skills
* Ability to work in a team environment
* Ability to prioritize workload to meet demands
Minimum Requirements
* Required: Current unrestricted LPN/RN nursing license (RN preferred but not required)
* Required: Experience p...
- Rate: 74000
- Location: Shreveport, US-LA
- Type: Permanent
- Industry: Finance
- Recruiter: Maximus
- Contact: Not Specified
- Email: to view click here
- Reference: 21036_LA_Shreveport
- Posted: 2024-05-07 08:38:20 -
- View all Jobs from Maximus
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