Consultant - Medical (Workers Compensation)

Description & Requirements

Maximus is currently hiring for Consultant - Medical to join our team.

This is a remote opportunity and contingent upon award of contract.

The Consultant will be responsible for providing independent medical reviews for prior authorization requests for relating to Workers' Compensation benefits (WC), Disability benefits (DB), Paid Family Leave (PFL) benefits, Volunteer Firefighters' benefits, and Volunteer Ambulance Workers' benefits.



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*Please note that this position is contingent upon contract award

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Essential Duties and Responsibilities:
- Review cases and summarize the facts of each case and assess issues involved in the case to certify or non-certify requested treatments.
- Provide written clinical rationales for CA Workers Compensation cases.
- Review, organize and identify all medical records provided for CA workers comp cases.
- Monitor timeliness of reviews to ensure applicable standards are met.
- Consistently meet production and quality standards.
- Perform special projects as assigned such as legal research, general medical research, etc.
- Work on special projects to improve CA IMR project or other special projects as assigned.
- Become a subject matter expert (SME) using job aides and learning tools.

- Review and provide independent medical reviews for prior authorization requests for relating to Workers' Compensation benefits (WC), Disability benefits (DB), Paid Family Leave (PFL) benefits, Volunteer Firefighters' benefits, and Volunteer Ambulance Workers' benefits.
- Evaluate Level 3 prior authorization requests (PARs) for medical services and goods including but not limited to all PAR types (Medication, Confirmation, Variance, Special Services, Durable Medical Equipment), all New York State Workers' Compensation Medical Treatment Guidelines and Drug Formulary criteria for all medical services, medications, medical devices contemplated therein, or requests for variances for medical treatment not addressed or recommended.

- Ensure all basic documentation requirements are available or requested via development action prior to review by medical and pharmacy review personnel.

- Render medical/clinical determinations based on professional experience that is clear, professional and grammatically correct.

- Ability to perform comfortably in a fast-paced, production and deadline-oriented work environment.

- Provide written clinical rationales for Workers Compensation cases.

- Review, organize and identify all medical records provided for prior authorization requests (PAR) for assigned workers comp cases.

- Monitor timeliness of reviews to ensure applicable standards are met.

- Consistently meet production and quality standards.

- Perform special projects as assigned such as clinical research, general medical research, etc.

- Become a subject matter expert (SME) using job aides and learning tools.

- Work on special projects as assigned.

- Other duties as assigned by management.

Minimum Requir...