Consultant - Medical (Case Reviewer 2)

This is a remote opportunity. A Federal Suitability Clearance is required post-hire as mandated by the client.

Responsibilities

• Review cases and summarize the facts of each case; assess issues to certify or non-certify requested treatments.
• Provide written clinical rationales for California Workers’ Compensation cases.
• Review, organize, and identify all medical records provided for California workers’ compensation cases.
• Monitor timeliness of reviews to ensure applicable standards are met.
• Consistently meet production and quality standards.
• Perform special projects such as legal research, general medical research, and projects to improve the CA Independent Medical Review (IMR) process.
• Become a subject matter expert (SME) using job aids and learning tools.
• Review and evaluate proposed Medicare set-aside arrangements, including submitted medical records, to determine if the proposed settlement meets threshold requirements and adequately considers Medicare’s interests regarding future medical service needs.
• 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 coding procedures and standards.
• Other duties as assigned by management.

Requirements

• Bachelor’s degree with 3–5 years of experience consulting within the designated function.
• Extensive documentation review and/or medical review experience.
• Ample medical knowledge and experience with medical terminology, ICD-9/10 codes, Current Procedure Terminology (CPT) codes, and 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 (including pre-planned vacations).
• Ability to pass a Federal Suitability Clearance.
• Must currently and permanently reside in the Continental US.

Preferred 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).
• Medicare Set-Aside Arrangement experience.
• Medical/Utilization Review experience.
• Knowledge of Healthcare Common Procedure Coding System (HCPCS) coding practices, Medicare coverage guidelines, anatomy, physiology, pharmacology, clinical practice guidelines, utilization review standards, state-specific workers’ compensation guidelines, and HIPAA regulations.

Home Office Requirements

• Internet speed of 25 Mbps or higher (50 Mbps for shared connectivity).
• Minimum 5 Mbps upload speed.
• Connectivity to the internet via Category 5 or 6 ethernet patch cable to the home router.
• Private and secure work area with adequate power source.
• Must have a smartphone for logging into Maximus systems.

Pay

Annual salary range: $70,000 – $75,000.