Clinical Nurse Consultant

Maximus; Denver (CO); On-site; USD 59,000 - 65,000; Full time

Job summary

Maximus is seeking a Clinical Nurse Consultant to join the Federal Exchange Review Process team. This remote role manages end-to-end medical reviews, assigns cases to the appropriate clinical reviewer, and ensures timely, compliant decisions.

A valid LPN or RN license is required. Experience with Salesforce or Axway and with medical records or health plan regulations is preferred. A Federal Suitability Clearance is required post-hire, and Maximus provides equipment.

Qualifications

• Valid, active LPN or RN license required.
• Experience reviewing medical records and/or health plan regulations preferred.
• Experience with Salesforce or Axway a plus.

Responsibilities

• Review favorable and partially favorable determinations in accordance with regulations.
• Render determinations for cases assigned.
• Resolve technical issues within reconsiderations.
• Review cases or sites to summarize facts and assess issues.
• Participate in general medical research or drafting proposal sections as needed.
• Perform duties as assigned by management.
• Review medical records to identify the appropriate clinical specialty required for review.

Skills

RN license

Clinical review experience

Communication skills

Tools

Salesforce

Axway

Job description

Maximus is currently hiring for a Clinical Nurse Consultant to join our Federal Exchange Review Process (FERP) team. This is a remote opportunity. The Consultant manages the end-to-end medical review process, ensuring cases are accurately assessed, assigned to the appropriate clinical specialty reviewer, and completed within established timelines. This role collaborates with healthcare providers, prepares case summaries and medical necessity documentation, and supports quality assurance to ensure timely and compliant review decisions.

This position will require a Federal Suitability Clearance post-hire as mandated by the client.

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 medical records and identify the appropriate clinical specialty required for review.

Preferred Skills and Qualifications:

• Valid, active LPN or RN license.

• Experience working with Salesforce and/or Axway.

• Experience reviewing medical records and/or health plan regulations.

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

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.

Minimum Salary

$59,000

Maximum Salary

$65,000