Clinical Reviewer- RN (Remote/DME Appeals/Discussion Demo)


The Nurse Reviewer - Medical Consultant is responsible for independently reviewing the medical records for Durable Medical Equipment cases and applying Medicare coverage policies to make a coverage determination. The Nurse Reviewer is responsible for making medical necessity determinations relating to whether an item is reasonable and necessary for the diagnosis or treatment of an illness or injury. The reviewer will then document the decision to be included in a final decision letter. Perform medical necessity reviews for Medicare QIC Durable Medical Equipment (DME) cases assigned Resolve all other technical issues within Medicare reconsideration assigned Review cases to determine and summarize facts of each case assigned and assesses issues involved in the case Review files to determine medical necessity of itmes at issue as well as determine coverage under Medicare Research issues using federal law and Medicare regulations/coverage policies Communicate the review findings in a clearly written report Meet or exceed all performance standards established for this position May 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 managementRegistered nurse (RN) degree with active license required and able to meet credentialing requirementsBachelor s Degree Knowledge of health regulations, guidelines and coverage issues; knowledge of statistical terminology and use of statistics; must possess strong analytical skills, problem solving and decision making skills, excellent organization, written and verbal communication skills, excellent computer skillsAbility to perform comfortably in a fast-paced, deadline-oriented work environment Ability to work independently and support team members (virtually)Ability to independently manage workflow; proficient in Microsoft Office software; Ability to quickly learn multiple database systems and comfortably manage multiple screens at the same timeTwo years of related experience

The Ideal Candidate will Possess the Following Additional Education and Experience

  • Bachelor's degree with 3-5 years of experience consulting within designated function.
  • Develops solutions to complex problems which require regular use of ingenuity and innovation.
  • Interprets applicable regulations and policies associated with case to determine recommendation.
  • Plans implementation, training, and solution deployment.
  • Ensures solutions are consistent with organization objectives.
  • Regularly contributes to the development of new concepts, techniques, and standards requiring varied interpersonal and technical skills.
  • Considered expert in field within the organization.

EEO Statement

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.

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