Consultant - Medical; Case Reviewer

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 WorkersâEUR(TM) Compensation Review Contractor.

This position will require a Federal Suitability Clearance post-hire as mandated by the client.

• Review cases and summarize the facts of each case and assess issues involved in the case to certify ornon-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 MedicareâEUR(TM) 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.
• Provide written clinical rationales for Workers Compensation cases.
• Review, organize and identify all medical records provided for workers comp cases.
• Other duties as assigned by management.

• Bachelor's degree with 3-5 years of experience consulting within designated function.
• 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 workersâEUR(TM) 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.

• 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.

• 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 workersâEUR(TM) compensation guidelines and pricing structure.
• Health Insurance Portability and Accountability Act (HIPAA) and related healthcare confidentiality regulations.

Maximus will provide equipment to use.

• Internet speed of 25mbps or higher required / 50 Mpbs for shared internet connectivity (you can test this by going to )
• 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…