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...
- Rate: 23.5
- Location: Duluth, US-MN
- Type: Permanent
- Industry: Finance
- Recruiter: Maximus
- Contact: Not Specified
- Email: to view click here
- Reference: 24739_MN_Duluth
- Posted: 2024-09-06 09:20:21 -
- View all Jobs from Maximus
More Jobs from Maximus
- Aushilfe als Paketsortierer (m/w/d)
- Aushilfe als Paketsortierer (m/w/d)
- Postbote für Pakete und Briefe (m/w/d)
- Maintenance Planner - Tissue
- R&D Maintenance Technologist
- Supplier Quality Engineer
- High Voltage Connector Project Engineer
- Senior Accountant
- Senior Accountant
- Test Lab Technician Sample Quality
- Paketzusteller (m/w/d)
- Instrument Reliability Engineer
- Janitor/Custodian - Holloman Air Force Base
- Janitor/Custodian - DHS Sarita Checkpoint
- Supervisor-Custodial- 129 Kingsville NAS | Kingsville Naval Air Station
- Employé Logistique F/H - CDI - Temps plein
- Financial Analysis Advisor
- Plan Automation Senior Analyst - Remote
- Program Management Senior Advisor - Express Scripts - Hybrid
- RN- Financial Nurse Case Manager- PACE Team- Accredo- Remote