Clinical Adjudicator - LPN (Remote)

Description & Requirements

Maximus is currently hiring for a Clinical Adjudicator - LPN to join our QIC DME team.

This is a remote opportunity.

The Clinical Adjudicator - LPN is responsible for medical reviews and applying Medicare coverage criteria to adjudicate clinical DMEPOS appeals, following project guidelines.

Essential Duties and Responsibilities:

- 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.

-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 DMEPOS cases

- Provide written clinical rationales for DMEPOS cases

- Monitor timeliness of reviews to ensure applicable standards are met

- Consistently meet production and quality standards

- 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

- Works on a variety of assignments requiring considerable judgement and initiatives

Requirements:

- Minimum of 1 year clinical experience considered in lieu of 2 year requirement

- Experience performing medical review for all DMEPOS categories within Medicare

- Candidates must be available for a training period scheduled from Monday - Friday 8:00am to 4:30pm EST

Minimum Requirements

- Current Licensed Practical Nurse (LPN) license valid in the state of practice is required

- High School Degree or equivalent required

- Minimum 2 years of clinical experience required

Preferred:

- 1 year in Medical Review experience at MAC, ZPIC/UPIC, RAC, SMRC, or QIC

- Experience with MAC, ZPIC / UPIC, RAC, SMRC or QIC

- Knowledge of CMS Internal Only Manuals and Medicare LCD/LCA requirements

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

Home Office Requirements:

- Internet speed of 20mbps 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 either Wi-Fi or Category 5 or 6 ethernet patch cable to the home router

- Private work area and adequate power source

- Must currently and permanently reside in the Continental US

EEO Statement

Active military service members, their spouses, and veteran candidates often embody the core competencies Maximus deems essential, and bring a resiliency and dependability that great...