Consultant - Medical (WCRC-CR2)

Job Description Summary

This position will review WCMSA case submissions in support of the Workers’ Compensation Review Contractor.Essential Job Duties:• 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.• Audit complex determinations for other clinical review programs utilizing medical records to ensure compliance with the organization's coding procedures and standards.• Other duties as assigned by management.Education and Experience Requirements:• Bachelor’s degree from an accredited college or university in Nursing; additional experience would be consider in lieu of degree.• 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 (obtainable within 3 months of hire) preferred.• Medical/Utilization Review experience preferred.• Medicare Set-Aside Arrangement experience required.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.Essential Duties and Responsibilities:- Review cases and summarize the facts of each case and assess issues involved in the case to certify or non-certify requested treatments.- Provide written clinical rationales for Workers Compensation cases.- Review, organize and identify all medical records provided for workers comp cases.- Monitor timeliness of reviews to ensure applicable standards are met.- Consistently meet production and quality standards.- Perform special projects as assigned such as legal research, general medical research, etc.- Work on special projects as assigned.- Become a subject matter expert (SME) using job aides and learning tools.

Job Summary

Essential Duties and Responsibilities:- Review cases and summarize the facts of each case and assess issues involved in the case to certify or non-certify requested treatments.- Provide written clinical rationales for CA Workers Compensation cases.- Review, organize and identify all medical records provided for CA workers comp cases.- Monitor timeliness of reviews to ensure applicable standards are met.- Consistently meet production and quality standards.- Perform special projects as assigned such as legal research, general medical research, etc.- Work on special projects to improve CA IMR project or other special projects as assigned.- Become a subject matter expert (SME) using job aides and learning tools.  Minimum Requirements:- Bachelor's degree with 3-5 years of experience consulting within designated function.

MAXIMUS Introduction

Since 1975, Maximus has operated under its founding mission of Helping Government Serve the People, enabling citizens around the globe to successfully engage with their governments at all levels and across a variety of health and human services programs. Maximus delivers innovative business process management and technology solutions that contribute to improved outcomes for citizens and higher levels of productivity, accuracy, accountability and efficiency of government-sponsored programs. With more than 30,000 employees worldwide, Maximus is a proud partner to government agencies in the United States, Australia, Canada, Saudi Arabia, Singapore and the United Kingdom. For more information, visit https://www.maximus.com.

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