Location: McLean
Company: Maximus Services
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 shop 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. • Other duties as assigned by management. Education and Experience Requirements: • Bachelor's degree from an accredited college or
university in Nursing; additional experience would be consider in lieu of degree. • At least 3 years' related experience 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.
• Medicare Set-Aside Certified Consultant (MSCC) certification (obtainable within 3 months of hire) preferred. • Medical/Utilization Review experience preferred. • Medicare Set-Aside Arrangement experience required. Additional Knowledge of: •Healthcare Common Procedure Coding System (HCPCS) coding practices.
•Medicare coverage guidelines. •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. Essential Duties and Responsibilities: - Review cases and summarize the facts of each case and backss 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. - Work on special projects as assigned. - Become a subject matter expert (SME) using job aides and learning tools. Job Summary Essential Duties and Responsibilities: - Review cases and summarize the facts of each case and backss 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. Minimum Requirements: - Bachelor's degree with 3-5 years of experience consulting within designated function. MAXIMUS Introduction Since 1975, Maximus has operated under its founding mission of Helping Government Serve the People, enabling citizens around the globe to successfully engage with their governments at all levels and across a variety of health and human services programs.
Maximus delivers innovative business process management and technology solutions that contribute to improved outcomes for citizens and higher levels of productivity, accuracy, accountability and efficiency of government-sponsored programs. With more than 30,000 employees worldwide, Maximus is a proud partner to government agencies in the United States, Australia, Canada, Saudi Arabia, Singapore and the United Kingdom.
For more information, visit. 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, interaction, interactionual orientation, gender identity, national origin, protected veteran status or disabled status.
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. Posted Max USD $65,000.00/Yr. Posted Min USD $42,400.00/Yr.
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