Workers Compensation Medical Case Reviewer (Remote Opportunity)

2 weeks ago(1/11/2018 11:49 AM)
Requisition ID
# of Openings
Job Function
Job Schedule
Regular Full-Time

Project/Position Introduction

MAXIMUS is a leading operator of government health and human services programs and has partnered with state, federal and local governments to provide critical, high quality health and human service programs to a diverse array of communities. Operating under MAXIMUS’s founding mission of Helping Government Serve the People® since 1975, MAXIMUS Federal Services is entirely focused on helping government agencies run programs cost-effectively and serve program constituents with improved outcomes. By being a responsible steward for government programs, we help the federal government deliver on its promises through our people, process and technology. Our focus is always on outcomes and results that connect citizens more effectively with government services.


The Workers Compensation Medical Case Reviewer is responsible for reviewing favorable and partially favorable determinations in accordance with applicable regulations.


This is a remote position.


  • 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 Medicare’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
  • Answer phone requests for status or additional information on development letters

The Ideal Candidate will Possess the Following Additional Education and Experience

  • Bachelor’s degree from an accredited college or university in Nursing required
  • At least 3 years’ related experience required
  • 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
  • Medicare Set-Aside Certified Consultant (MSCC) certification will be required to obtain within 3 months of hire; paid by company
  • Medical/Utilization Review experience preferred
  • Workers Comp or Medicare Set-Aside Arrangement experience preferred
  • 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

EEO Statement

EEO Statement
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.


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