Consultant - Medical (RN) Case Reviewer 2

Description & Requirements

Maximus is currently hiring for a Consultant - Medical (RN) Case Reviewer 2 to join our WCRC team.

This is a remote opportunity.

The Consultant will review WCMSA case submissions in support of the Workers' Compensation Review Contractor.

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 evaluate proposed Medicare set-aside arrangements, including submitted medical records, to determine if the proposed settlement meets the threshold requirements established for beneficiaries and potential beneficiaries and adequately considers Medicare's interests as pertaining to future medical service needs of beneficiaries

- 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.

- Implement operating rules and CMS policy.

- Audit complex determinations for other clinical review programs utilizing medical records to ensure compliance with the organization's coding procedures and standards.

- 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 Workers Compensation cases.

- Review, organize and identify all medical records provided for 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.

- 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 Requirements

- Bachelor's degree with 3-5 years of experience consulting within designated function.

- Relevant professional experience can be considered in lieu of Bachelor's degree.

- Valid RN licensure required.

- Ability to commit to a two-week training period between the hours of 9:00am - 6:00pm EST Monday - Friday required.

- Flexibility in work hours, post-training, to include more than 40-hours a week based on business needs required.

- Possess ample medical knowledge and experience with medical terminology...