Appeals Nurse

Description & Requirements

Maximus is currently hiring for an Appeals Nurse to join our State East team.

This is a remote opportunity.

The Appeals Nurse is responsible for facilitating the review portion of the case.

They will review the medical records, prepare the case files for the expert reviewer, and select the expert specialty to conduct the review.

Additionally, they are responsible for completing a quality check of the final document and ensuring the report address the issue at hand and meets all state, and client requirements.



*An active, unrestricted RN License is required for this position

*

Essential Duties and Responsibilities:

- Responsible for reviewing favorable and partially favorable determinations in accordance with applicable regulations.

- Render medical necessity 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 expert review findings and prepare determination letters.
- Communicate the determination in a succinct written or verbal format.
- Exercise independent judgment to ensure determination is accurate, well-supported, and defensible.
- 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.
- Experience in health care appeals, health care claims, and familiarity with medical terminology and/or medical record review beneficial.

Minimum Requirements

- Bachelor's degree required

- Active RN license required.

- Minimum 2 years clinical experience required with RN license.

- Ability to work a schedule of 8:00am - 5:00pm EST Monday - Friday preferred.

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 and secure work area and adequate power source

- Must currently and permanently reside in the Continental US

EEO Statement

Maximus is an equal opportunity employer.

We evaluate qualified applicants without regard to race, color, religion, sex, age, national origin, disability, veteran status, genetic information and other legally protected characteristics.

Pay Transparency

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