Clinical Adjudicator - LPN/RN (Remote)

Description & Requirements Maximus is currently hiring for Clinical Adjudicators - LPN/RN to join our QIC DME team. This is a remote opportunity. The Clinical Adjudicator is responsible for medical reviews and applying Medicare coverage criteria to adjudicate clinical DMEPOS appeals, following project guidelines. Essential Duties and Responsibilities: - Responsible for reviewing documentation and/or assessments and applying clinical criteria to complete determinations, approvals or recommendations. - Determine need for and obtain any additional information required to complete actions. - Determine when escalation or consultation is required with supervisor, physician or related medical or related clinical discipline. - Complete reports or documentation in accordance with contract requirements. - Performs other related duties as assigned. -Responsible for reviewing documentation and applying Medicare coverage criteria to adjudicate clinical DMEPOS appeals, following project guidance. - Review, organize and identify all medical records provided for DMEPOS cases. - Provide written clinical rationales for DMEPOS cases. - Monitor timeliness of reviews to ensure applicable standards are met. - Consistently meet production and quality standards. - Become a subject matter expert (SME) using job aides and learning tools. - Work on assignments that are moderately difficult, requiring judgement in resolving issues. - Understand implications of work and make recommendations for solutions. - Works on a variety of assignments requiring considerable judgement and initiatives. Minimum Requirements - Current Licensed Practical Nurse (LPN) license valid in the state of practice is required - High School Degree or equivalent required - Minimum 2 years of clinical experience required - Candidates must be available for a training period scheduled from 8:00am to 4:30pm EST Monday - Friday - Knowledge of CMS Internal Only Manuals and Medicare LCD/LCA requirements preferred - Experience performing medical review for all DMEPOS categories within Medicare preferred Please note: For this position Maximus will provide equipment to use. Home Office Requirements: - Internet speed of 20mbps or higher required / 50 Mpbs for shared internet connectivity (you can test this by going to www.speedtest.net) - Minimum 5mpbs upload speed - Connectivity to the internet via either Wi-Fi or Category 5 or 6 ethernet patch cable to the home router - Private work area and adequate power source - Must currently and permanently reside in the Continental US 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. 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. Minimum Salary $ 23.50 Maximum Salary $ 23.50 • Remote About the Company: Maximus MAXIMUS provides business services to help governments operate health and human services programs, mostly at the state and national levels. The company's health services segment offers outsourced program management and administrative services, Company Size: 5,000 to 9,999 employees Industry: Healthcare Services Founded: 0 Website: https://www.maximus.com/ Apply tot his job Apply To this Job