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...