- Extensive documentation review and/or medical review experience.
- 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.
- Availability during core business hours EST Monday - Friday.
- Ability to commit to a training period with zero absences (to include pre-planned vacations).
- Ability to pass a Federal Suitability Clearance.
Preferred Skills and Qualifications:
- Bachelor's degree from an accredited institution in Nursing, Pharmacy (PharmD), or other healthcare-related clinical discipline.
- Active, valid RN licensure.
- Medicare Set-Aside Certified Consultant (MSCC) certification (obtainable within 3 months of hire).
- Medical/Utilization Review experience.
- Medicare Set-Aside Arrangement experience.
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.
Please note: For this position Maximus will provide equipment to use.
Home Office Requirements:
- Internet speed of 25mbps 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 Category 5 or 6 ethernet patch cable to the home router
- Private and secure work area and adequate power source
- Must currently and permanently reside in the Continental US
- Must have a smartphone which will be required to log into Maximus systems