Clinical Reviewer LPN - (Remote)

MAXIMUS; Lebanon (NH); Hybrid; USD 41,000 - 49,000; Full time

Job summary

Maximus seeks a qualified clinical reviewer to assess requests for services, including admissions and discharges, ensuring adherence to clinical criteria, policy, and contract requirements. You will issue determinations, request additional documentation, and document activities in contract systems.

The role emphasizes collaboration with providers and state personnel, coaching peers, and potentially updating guidelines.

Qualifications

• Specific clinical license and experience requirements based on contract requirements.
• Associate degree in Nursing.
• An active LPN license in the state of Colorado or a compact license is required.
• Minimum 2 years of experience working with people with complex disabilities, including pediatric and geriatric populations.
• Familiarity with Home and Community Based Services waivers (HCBS).
• Proficiency in Microsoft Office applications.

Responsibilities

• Review requests for services, including admissions, discharges, and continued stays for adherence to clinical criteria and contract requirements.
• Issue approvals, denials, or recommendations based on contract requirements and standards.
• Identify the need for additional documentation or consultation and analyze information gaps.
• Complete accurate documentation of review activities within contract systems.
• Communicate and collaborate with providers, state workers, and external stakeholders to clarify requirements and support program outcomes.
• Provide guidance, coaching, training and quality review for team members; improve review processes.
• May meet with external clients to confirm and update clinical guidelines.
• May write high-quality, fully substantiated clinical determination reports, including the summary of findings.

Skills

Microsoft Office

Communication skills

Education

Associate degree in Nursing

Active LPN license in CO or compact state

Job description

Essential Duties and Responsibilities

• Review requests for services, including admissions, discharges, and continued stays for adherence to clinical criteria, state and federal policy, and contract requirements involving broad clinical complexity and variability; apply subject matter expertise to ensure consistency and drive quality outcomes; and escalation exceptions to policies.
• Issue approvals, denials, or recommendations based on contract requirements; ensure quality, consistency, and adherence to clinical and regulatory standards across cases.
• Identify the need for additional clinical documentation or consultation and analyze information gaps to support accurate and timely determinations.
• Complete accurate documentation of review activities within contract systems.
• Communicate and collaborate with providers, individuals and their designees, state workers, and external stakeholders to clarify requirements, resolve issues, and support program outcomes.
• Provide guidance, coaching, training and quality review for team members; identify opportunities to improve review processes and consistency.
• May meet with external clients to confirm and update clinical guidelines that must be followed internally.
• May write high-quality, fully substantiated clinical determination reports by synthesizing assessment findings, interview data, and supporting documentation, including completing the summary of findings.

Minimum Requirements

• Specific clinical license and experience requirements based on contract requirements.
• Associate degree in Nursing
• An active LPN license in the state of Colorado or a compact license is required
• Minimum 2 years of experience working with people with complex disabilities, including pediatric and geriatric populations
• Familiarity with Home and Community Based Services waivers (HCBS)
• Proficiency in Microsoft Office applications

Preferred Requirements:

• Prior experience conducting document-based reviews
• Excellent written and communication skills
• Previous experience working remotely
• Prior experience conducting document-based reviews

Home Office Requirements:

• Maximus provides company-issued computer equipment
• Reliable high-speed internet service
• Minimum 20 Mpbs download speeds/50 Mpbs for shared internet connectivity
• Minimum 5 Mpbs upload speeds
• Private and secure workspace

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

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.

Accommodations

Maximus provides reasonable accommodations to individuals requiring assistance during any phase of the employment process due to a disability, medical condition, or physical or mental impairment. If you require assistance at any stage of the employment process-including accessing job postings, completing assessments, or participating in interviews,-please contact People Operations at [e-mail].

Minimum Salary

$

29.86

Maximum Salary

$

35.48