Sr Consultant, Medical Ops

Description & Requirements
Maximus is looking for a Sr. Consultant - Clinical Ops with QIC Experience. This is a fully remote role.
The Sr. Consultant - Clinical Ops serves as the point of contract (POC) for allocating work and providing education, guidance and training to team members for DMEPOS appeal adjudication.
Essential Duties and Responsibilities:
- Responsible for reviewing favorable, and partially favorable, determinations in accordance with applicable regulations.
- Render medical necessity determinations for Medicare State East cases assigned.
- Resolve all other technical issues within Medicare reconsideration assigned.
- Review cases to determine and summarize facts of each case assigned and assess issues involved in the case.
- 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.
- Be the Subject Matter Expert (SME) for project.
- Perform other duties as assigned by management.
Essential Duties and Responsibilities:
Performs adjudication on all DMEPOS appeal case types. 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 DME cases. Provide written clinical rationales for DMEPOS cases. Monitor timeliness of reviews to ensure applicable standards are met. Consistently meet production and quality standards. Perform other related duties and/or special projects as assigned. 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. Communicate on complex or sensitive issues or draft such responses for manager. Works on a variety of assignments requiring considerable judgement and initiative. As a skilled and experienced specialist, completes tasks in resourceful and effective ways. Able to draft or modify training materials and procedural documentation accurately. Skilled in handling challenging communications. Act independently to determine methods and procedures on new assignments. Perform quality assurance on work of others in team. Position Requirements:
Excellent verbal and written communication skills Proven organization and time management skills Leadership and teaching skills to educate others People skills Problem solving and analytical skills Ability to work in a team environment Ability to prioritize workload to meet demands Minimum Requirements
Required: Current unrestricted LPN/RN nursing license (RN preferred but not required) Required: Experience performing medical review for all DMEPOS categories within Medicare Required: 2+ years of leadership experience Preferred: 2+ years in Medical Review experience at MAC, ZPIC/UPIC, RAC, SMRC or QIC with extensive knowledge of CMS Internet Only Manuals and Medicare LCD/LCA requirements Home Office Requirements:
Reliable high-speed internet service Minimum 20 Mpbs download speeds/50 Mpbs for shared internet connectivity Minimum 5 Mpbs upload speeds Private workspace away from others, noise and distractions Additional Requirements (i.e., BYO headsets, hard wire connection, etc.)
Minimum Requirements
Minimum Requirements:
- Bachelor's degree with 5-7 years of experience consulting within designated function.
- Advanced degree preferred.
- Develop solutions to highly complex problems which require a high degree of ingenuity and innovation.
- Ensure solutions are consistent with organization objectives.
- Solutions may serve as precedent for future decisions.
- Develop advanced concepts, techniques, and standards requiring a high level of interpersonal and technical skills.
- Develop new applications based on professional principles and theories.
- Viewed as expert in field within the organization.
Essential Duties and Responsibilities:
Performs adjudication on all DMEPOS appeal case types. 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 DME cases. Provide written clinical rationales for DMEPOS cases. Monitor timeliness of reviews to ensure applicable standards are met. Consistently meet production and quality standards. Perform other related duties and/or special projects as assigned. 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. Communicate on complex or sensitive issues or draft such responses for manager. Works on a variety of assignments requiring considerable judgement and initiative. As a skilled and experienced specialist, completes tasks in resourceful and effective ways. Able to draft or modify training materials and procedural documentation accurately. Skilled in handling challenging communications. Act independently to determine methods and procedures on new assignments. Perform quality assurance on work of others in team. Position Requirements:
Excellent verbal and written communication skills Proven organization and time management skills Leadership and teaching skills to educate others People skills Problem solving and analytical skills Ability to work in a team environment Ability to prioritize workload to meet demands Minimum Requirements
Required: Current unrestricted LPN/RN nursing license (RN preferred but not required) Required: Experience performing medical review for all DMEPOS categories within Medicare Required: 2+ years of leadership experience Preferred: 2+ years in Medical Review experience at MAC, ZPIC/UPIC, RAC, SMRC or QIC with extensive knowledge of CMS Internet Only Manuals and Medicare LCD/LCA requirements Home Office Requirements:
Reliable high-speed internet service Minimum 20 Mpbs download speeds/50 Mpbs for shared internet connectivity Minimum 5 Mpbs upload speeds Private workspace away from others, noise and distractions Additional Requirements (i.e., BYO headsets, hard wire connection, etc.)
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.