Job descriptionEssential Duties and Responsibilities: - Responsible for reviewing favorable, and partially favorable, determinations in accordance with applicable regulations. - Render medical necessity determinations for Medicare State East cases assigned. - Resolve all other technical issues within Medicare reconsideration assigned. - Review cases to determine and summarize facts of each case assigned and assess issues involved in the case. - May 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. - Be the Subject Matter Expert (SME) for project. - Perform other duties as assigned by management. - Demonstrated skill in understanding diagnoses to assist clients in optimizing their level of function and self-care. - Demonstrated knowledge of client education principles and the management of complex medical, psychosocial, and financial problems to enhance adherence to individualized treatment plans and train peers and staff. - Knowledge and skills in the use of VA/DoW Clinical Practice Guidelines to support an evidence based, standardized process of care for military beneficiaries. - Knowledge of the healthcare financial environment and the fiscal dimension of population health to ensure optimal stewardship of resources. - Skill in the use of research tools to critically evaluate existing practices, opportunities, and outcomes. - Knowledge of pharmaceuticals, including desired effects, side effects, and complications, to gauge their effect on clients and recovery. - Knowledge of community resources, client entitlement and benefit eligibility, and the ability to access these resources to assist clients and families in optimizing function and self-care. - Use of pre-established utilization and review criteria, and the ability to recognize and report actual or potential quality and risk management issues to improve practice and ensure compliance. - Use of information systems and technology to manage individual or population health, continuously improve practice, and effectively communicate practice outcomes to stakeholders. - Use of computers and software applications to conduct data collection, tracking, trending, and analysis, and to design and present computer-generated outcome analyses for educational programs or project briefings. Minimum Requirements - Bachelor's degree with 5-7 years of experience consulting within designated function. - Advanced degree preferred. - Develop solutions to highly complex problems which require a high degree of ingenuity and innovation. - Ensure solutions are consistent with organization objectives. - Solutions may serve as precedent for future decisions. - Develop advanced concepts, techniques, and standards requiring a high level of interpersonal and technical skills. - Develop new applications based on professional principles and theories. - Viewed as expert in field within the organization. - Active RN license OR Active Licensed Clinical Social Worker (LCSW) license with a minimum two (2) year nursing degree from an accredited institution. - Minimun of (2) years of nursing and/or case management experience. - Certification as a case manager by a recognized certifying organization, such as the Commission for Case Manager Certification, American Case Management Association, or American Nurses Credentialing Center; or ability to obtain certification within one (1) year of hire. - Professional oral and written communication skills with peers, outside agencies, vendors, providers, and Military Health System stakeholders. - Skill in team coordination, facilitation, and communication to support information exchange, goal achievement, client support networks, and change in systems or policies. Preferred Requirement - Licensed Clinical Social Worker (LCSW) licensure Home Office Requirements -Maximus provides company-issued computer equipment -Reliable high-speed internet service -Minimum 20 Mpbs download speeds/50 Mpbs for shared internet connectivity -Minimum 5 Mpbs upload speeds 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. Accommodations Maximus provides reasonable accommodations to individuals requiring assistance during any phase of the employment process due to a disability, medical condition, or physical or mental impairment.
If you require assistance at any stage of the employment process-including accessing job postings, completing assessments, or participating in interviews,-please contact People Operations at applicantaccom@maximus.com. Minimum Salary $ 73,950.00 Maximum Salary $ 105,850.00 *
