Consultant - Medical (Case Reviewer 2)

MAXIMUS; Newark (NJ); Remote; USD 68,000 - 72,000; Full time

Job summary

An established industry player is seeking a Consultant - Medical to join their remote WCRC team. In this role, you'll review and assess WCMSA case submissions, ensuring compliance with medical standards while providing clinical rationales for treatments. You'll work on special projects and become a subject matter expert, contributing to the improvement of the CA IMR project. This position offers a unique opportunity to apply your medical knowledge and experience in a dynamic environment that values quality and production standards. Join a team that prioritizes excellence and makes a meaningful impact in the field of workers' compensation.

Benefits

Health Insurance

Life and Disability Insurance

Retirement Savings Plan

Paid Holidays

Paid Time Off

Equipment Provided

Qualifications

• 3-5 years of consulting experience in designated function.
• Relevant professional experience can substitute for degree.

Responsibilities

• Review and summarize WCMSA case submissions.
• Provide clinical rationales for Workers Compensation cases.
• Ensure compliance with documentation requirements.

Skills

Medical Knowledge

ICD-9/10 Codes

Current Procedure Terminology (CPT)

Utilization Review Standards

Education

Bachelor's Degree

RN Licensure

Job description

Maximus is currently hiring for a Consultant - Medical (Case Reviewer 2) to join our WCRC team. This is a remote opportunity. The Consultant will review WCMSA case submissions in support of the Workers' Compensation Review Contractor.

Essential Duties and Responsibilities :

• Review cases and summarize the facts of each case and assess issues involved in the case to certify or non-certify requested treatments.
• Provide written clinical rationales for CA Workers Compensation cases.
• Review, organize and identify all medical records provided for CA workers comp cases.
• Monitor timeliness of reviews to ensure applicable standards are met.
• Consistently meet production and quality standards.
• Perform special projects as assigned such as legal research, general medical research, etc.
• Work on special projects to improve CA IMR project or other special projects as assigned.
• Become a subject matter expert (SME) using job aides and learning tools.
• Review and evaluate proposed Medicare set-aside arrangements, including submitted medical records, to determine if the proposed settlement meets the threshold requirements established for beneficiaries and potential beneficiaries and adequately considers Medicare's interests as pertaining to future medical service needs of beneficiaries
• Ensure all basic documentation requirements are available or requested via development action prior to review by medical and pharmacy review personnel.
• Render medical / clinical determinations based on professional experience.
• Implement operating rules and CMS policy.
• Audit complex determinations for other clinical review programs utilizing medical records to ensure compliance with the organization's coding procedures and standards.
• Review cases and summarize the facts of each case and assess issues involved in the case to certify or non-certify requested treatments.
• Provide written clinical rationales for Workers Compensation cases.
• Review, organize and identify all medical records provided for workers comp cases.
• Monitor timeliness of reviews to ensure applicable standards are met.
• Consistently meet production and quality standards.
• Perform special projects as assigned such as legal research, general medical research, etc.
• Become a subject matter expert (SME) using job aides and learning tools.
• Work on special projects as assigned.
• Other duties as assigned by management.
• Bachelor's degree with 3-5 years of experience consulting within designated function.
• Relevant professional experience can be considered in lieu of Bachelor's degree.
• RN licensure preferred.
• Ability to commit to a two-week training period between the hours of 9 : 00am - 6 : 00pm EST Monday - Friday required.
• Flexibility in work hours, post-training, to include more than 40-hours a week based on business needs required.
• Possess ample medical knowledge and experience with medical terminology, ICD-9 / 10 Codes, Current Procedure Terminology Codes (CPT) codes, with exposure to applying actual costs and workers' compensation fee schedules in pricing medical items and services.

Preferred Skills and Qualificiations :

• Medicare Set-Aside Certified Consultant (MSCC) certification (obtainable within 3 months of hire) preferred.
• Anatomy, physiology, and pharmacology.
• Clinical practice guidelines.
• Utilization review standards and practices.
• State-specific workers' compensation guidelines and pricing structure.
• Health Insurance Portability and Accountability Act (HIPAA) and related healthcare confidentiality regulations.

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 www.speedtest.net)
• 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

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.

Minimum Salary

68,000.00

Maximum Salary

72,000.00

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