Job Description
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
- 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 work area and adequate power source
- Must currently and permanently reside in the Continental US
EEO Statement
Active military service members, their spouses, and veteran candidates often embody the core competencies Maximus deems essential, and bring a resiliency and dependability that greatly enhances our workforce. We recognize your unique skills and experiences, and want to provide you with a career path that allows you to continue making a difference for our country. We're proud of our connections to organizations dedicated to serving veterans and their families. If you are transitioning from military to civilian life, have prior service, are a retired veteran or a member of the National Guard or Reserves, or a spouse of an active military service member, we have challenging and rewarding career opportunities available for you. A committed and diverse workforce is our most important resource. Maximus is an Affirmative Action/Equal Opportunity Employer. Maximus provides equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status or disabled status.
Pay Transparency
Maximus compensation is based on various factors including but not limited to job location, a candidate's education, training, experience, expected quality and quantity of work, required travel (if any), external market and internal value analysis including seniority and merit systems, as well as internal pay alignment. Annual salary is just one component of Maximus's total compensation package. Other rewards may include short- and long-term incentives as well as program-specific awards. Additionally, Maximus provides a variety of benefits to employees, including health insurance coverage, life and disability insurance, a retirement savings plan, paid holidays and paid time off. Compensation ranges may differ based on contract value but will be commensurate with job duties and relevant work experience. An applicant's salary history will not be used in determining compensation. Maximus will comply with regulatory minimum wage rates and exempt salary thresholds in all instances.
Minimum Salary
$
56,000.00
Maximum Salary
$
74,000.00
Job Tags
Minimum wage, Holiday work, Permanent employment, Contract work, Temporary work, Work experience placement, Remote job, Home office, Currently hiring, Flexible hours, Weekend work,