- 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 cases to identify and summarize key facts of each case and assess issues involved in the appeal;
- Research issues using current peerreviewed medical literature, clinical guidelines, applicable state laws and regulations, and other sources as defined by the client contract;
- Determine the adequacy of medical records and request relevant medical records as needed;
- Review expert review findings and prepare determination letters;
- Communicate the determination in a succinct written format;
- Exercise independent judgment to ensure determination is accurate, wellsupported, and defensible;
- Perform other special projects not related to a specific case, such as general medical or legal research, drafting proposal sections, or acting as a liaison for a specific project, when needed;
- Provide and holiday coverage on scheduled rotation; and
- Perform other duties as assigned by management.
- Bachelor's degree with 5 years of experience OR Associate's degree with 7 years of experience; experience in health care appeals or health care claims, preferred;
- Ability to successfully execute many complex tasks simultaneously and prioritize tasks according to urgency;
- Ability to respond to the needs of outside contacts;
- Working knowledge and use of PC, MS Word and Excel software;
- Ability to work as a part of a team as well as independently, and promote positive company relations;
- Excellent organizational, interpersonal, written, and verbal communication skills;
- Familiarity with medical terminology and/or medical record review.
- LPN Required
- Reliable high speed internet service
- Minimum 25 Mpbs download speeds/50 Mpbs for shared internet connectivity
- Minimum 5 Mpbs upload speeds
- Bachelor's degree with 5 years of experience, OR Associate's degree with 57 years of experience.
- RN preferred
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Nurse - Consultant - Fargo, United States - MAXIMUS
Description
Description & RequirementsMaximus is looking to fill a Nurse Consultant position.
This role includes reviewing medical records, resolving technical issues, assessing facts, and undertaking special projects such as legal and medical research, proposal drafting, and project liaison duties as directed by management.
Essential Duties and Responsibilities:
Home Office Requirements:
Minimum Requirements:
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, sex, sexual orientation, gender identity, national origin, protected veteran status or disabled status.
