Specialist - Nursing, RN

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.

- Reports directly to QIC Adjudication Manager.
- Perform technical appeal review under the direction of the professional clinical reviewers and the QIC Adjudication Manager.

- Review ISO compliant work instruction, process documents, and medical review templates as directed by QIC Adjudication Manager.

- Assist other projects or departments as directed by QIC Adjudication Manager.

- Understand workflow process and offer suggestions for improvement.

- Perform other duties as assigned by QIC Adjudication Manager.

- Must meet or exceed daily productivity requirements.

- Must maintain a QA score of 95 - 100%.

Minimum Requirements

- Bachelor's degree required

- Active RN license required.

- Minimum 2 years clinical experience required with RN license.

- Continuing education courses as required by state to maintain RN license.

- Ability to redirect work focus, as business need or workload volumes dictate.

- Ability to work independently in a remote setting.

- Critical thinking and analytical skills.

- Excellent written and oral communication skills.

- Strong organizational skills and attention to detail.

- Strong computer skills and knowledge of MS Office Suite, Chrome, Microsoft Edge.

- Ability to work an 8-hour schedule between the hours of 7:30am - 6:00pm EST Monday - Friday required.

Preferred Skills & Experience:
- Clinical experience in an acute or long-term care setting.

- Certification in ICD-10 billing and coding.

- Knowledge of Medicare Part A and/or Part B of A.

- Clinical training, education, or certification.

- Experience in production-based environment.

Please note: For this position Maximus will provide equipment to use.

Home Office Requirements:

- Internet speed of 25mbps 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 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

- Must have a smartphone which will be required to log into Maximus systems

EEO Statement

Maximus is an equal opportunity employer.

We evaluate qualified applicants without regard to race, color, religion, sex, age, national origin, disabili...