Consultant - Nurse

Description & Requirements

Maximus is currently hiring for a Consultant - Nurse to join our State East Appeals team.

This is a remote opportunity.

The Consultant - Nurse is responsible for composing written determinations as the final output in the process of independent third-party review.

Essential Duties and Responsibilities:
- Responsible for reviewing favorable and partially favorable determinations in accordance with applicable regulations.
- Render determinations for cases assigned.
- Resolve all other technical issues within reconsideration assigned.
- Review cases or sites assigned to determine and summarize facts and assess any issues identified.

- 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.
- Perform other duties as assigned by management.

- Review cases to identify and summarize key facts of each case and assess issues involved in the appeal.

- Research issues using current peer-reviewed medical literature, clinical guidelines, applicable state laws and regulations, and other sources as defined by the client contract.

- Determine the adequacy of medical records and request relevant medical records as needed.

- Review expert review findings and prepare determination letters.

- Communicate the determination in a succinct written format.

- Exercise independent judgment to ensure determination is accurate, well-supported, and defensible.

- Perform other special projects not related to a specific case, such as general medical or legal research, drafting proposal sections, or acting as a liaison for a specific project, when needed.

- Ability to successfully execute many complex tasks simultaneously and prioritize tasks according to urgency.

- Ability to respond to the needs of outside contacts.

- Working knowledge and use of PC, MS Word and Excel software.

- Ability to work as a part of a team as well as independently, and promote positive company relations.

- Excellent organizational, interpersonal, written, and verbal communication skills.

Minimum Requirements

- Bachelor's degree with 3 - 5 years of experience, OR Associate's degree with 5-7 years of experience.

- LPN required, RN preferred.

- Ability to provide weekend and holiday coverage on scheduled rotation required.

- Flexible work schedule to best support client needs required.

- Experience using PubMed and/or InterQual preferred.

- Experience in health care appeals, health care claims, and familiarity with medical terminology and/or medical record review beneficial.

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 o...