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.
This position is required to be On-Site Pittsford, NY Office; (remote work is not available). The Nurse Reviewer - Medical Consultant is responsible for independently reviewing the medical records and application of Federal and State regulations to determine status of appeals. An additional area of focus includes clinical analysis of peer review cases in connection with settled malpractice/tort claims.
• Research issues using federal and state law, federal and state regulations, relevant contract law and other sources as defined by the client contract
• 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
• Render medical necessity determinations for Medicare State reconsideration cases assigned
• Resolve all other technical issues within Medicare reconsideration assigned
• Review cases to determine and summarize facts of each case assigned and assesses issues involved in the case
• Review file to determine whether all relevant information has been submitted
• Demonstrate teamwork and promote positive company relations
• Perform other duties as assigned by management
• Bachelor’s Degree from an accredited college or university required
• Registered Nurse degree with active license
• Must be able and willing to attain a MA Nursing License within 3 months
• At least five (5) years of related experience required
• Experience in general medical care of patients preferred
• Exposure to workers' compensation coverage issues a plus
• Knowledge of health regulations, guidelines and coverage issues
• Knowledge of statistical terminology and use of statistics
• Excellent organizational, written, and verbal communication skills
• Ability to perform comfortably in a fast-paced, deadline-oriented work environment
• Ability to work as a team member, as well as independently
The Ideal Candidate will Possess the Following Additional Education and Experience
- Bachelor's degree with 3-5 years of experience consulting within designated function.
- Develops solutions to complex problems which require regular use of ingenuity and innovation.
- Interprets applicable regulations and policies associated with case to determine recommendation.
- Plans implementation, training, and solution deployment.
- Ensures solutions are consistent with organization objectives.
- Regularly contributes to the development of new concepts, techniques, and standards requiring varied interpersonal and technical skills.
- Considered expert in field within the organization.
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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