Consultant - Medical (Case Reviewer 2)

Maximus; Denver (CO); Remote; USD 68,000 - 72,000; Full time

Job summary

An established industry player is seeking a dedicated Consultant to join their remote WCRC team. This role involves reviewing and certifying medical cases, ensuring compliance with Medicare guidelines, and maintaining high production standards. Ideal candidates will bring strong medical knowledge and experience in utilization review. The company offers competitive compensation and a supportive work environment, along with comprehensive benefits, making it an excellent opportunity for professionals looking to advance their careers in the medical field.

Benefits

Health insurance

Retirement plans

Paid holidays

Equipment provided

Qualifications

• 3-5 years of relevant experience or equivalent professional experience.
• Strong medical knowledge, including terminology and coding.

Responsibilities

• Review WCMSA case submissions and provide clinical rationales.
• Organize and review medical records for workers' comp cases.

Skills

Medicare Set-Aside Certified Consultant (MSCC)

Medical/Utilization Review

ICD, CPT codes

Workers' compensation fee schedules

HIPAA compliance

Education

Bachelor's degree

Job description

Description & Requirements Maximus is currently hiring for a Consultant - Medical (Case Reviewer 2) to join our WCRC team.

This is a remote opportunity.

Responsibilities:

1. Review WCMSA case submissions to support the Workers' Compensation Review Contractor, including summarizing facts, assessing issues, and certifying or non-certifying treatments.
2. Provide written clinical rationales for CA Workers Compensation cases.
3. Organize and review medical records for CA workers' comp cases.
4. Monitor review timeliness to meet standards.
5. Maintain production and quality standards.
6. Perform legal and medical research, and other special projects to improve processes.
7. Become a subject matter expert using available tools.
8. Review and evaluate proposed Medicare set-aside arrangements to ensure compliance and adequacy.
9. Ensure all documentation is available before review.
10. Render clinical determinations based on experience, implementing CMS policies.
11. Audit complex determinations for compliance.
12. Other duties as assigned.

Minimum Requirements:

• Bachelor's degree with 3-5 years of relevant experience or equivalent professional experience.
• RN licensure preferred.
• Ability to commit to a two-week training (9:00am - 6:00pm EST, Mon-Fri).
• Flexibility to work more than 40 hours post-training.
• Strong medical knowledge, including terminology, ICD, CPT codes, and workers' compensation fee schedules.

Preferred Skills and Qualifications:

• Medicare Set-Aside Certified Consultant (MSCC) certification (preferred within 3 months).
• Experience in Medical/Utilization Review, Medicare Set-Aside Arrangements.
• Knowledge of HCPCS codes, Medicare guidelines, anatomy, physiology, pharmacology, clinical guidelines, utilization review standards, and state-specific workers' compensation regulations.
• Understanding of HIPAA and healthcare confidentiality.

Home Office Requirements:

• Internet speed of 20 Mbps or higher (50 Mbps for shared connections).
• Minimum 5 Mbps upload speed.
• Connectivity via Wi-Fi or Ethernet to home router.
• Private work area with adequate power.
• Residency in the Continental US.

Additional Information:

Maximus provides equipment. Compensation ranges from $68,000 to $72,000 annually, based on experience and other factors. Benefits include health insurance, retirement plans, paid holidays, and more. Salary history is not considered, and compliance with wage laws is maintained.