Clinical Adjudicator - LPN/RN (Remote)

Description & Requirements

Maximus is currently hiring for Clinical Adjudicators - LPN/RN to join our QIC DME team.

This is a remote opportunity.

The Clinical Adjudicator 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.

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

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

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

- Experience performing medical review for all DMEPOS categories within Medicare preferred

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 greatly enhances our workforce.

We recognize your unique skills and experiences, and want to provide you with a career path that allows you to continue making a difference for our country.

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