Clinical Review Specialist - Registered Nurse (Remote in Tennessee) ID-8033

Description & Requirements

Maximus is hiring a Clinical Review Specialist - Registered Nurse to join our Audit and Appeals team! In this role, you will evaluate submitted appeals and make decisions based on clinical evidence.

If you're passionate about making a positive impact in healthcare and have a keen eye for detail , apply today!

This is a remote position, and candidates must reside in Tennessee.

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Why Maximus?

  • 🔄 Work/Life Balance Support – Flexibility tailored to your needs!
  • 💰 Competitive Compensation – Bonuses based on performance included!
  • 🛡️ Comprehensive Insurance Coverage – Choose from various plans, including Medical, Dental, Vision, Prescription, and partially funded HSA. Additionally, enjoy Life insurance benefits and discounts on Auto, Home, Renter's, and Pet insurance.
  • 🌟 Future Planning – Prepare for retirement with our 401K Retirement Savings plan and Company Matching.
  • 🏝️ Paid Time Off Package – Enjoy PTO, Holidays, and extended sick leave, along with Short and Long Term Disability coverage.
  • 🌱 Holistic Wellness Support – Access resources for physical, emotional, and financial wellness through our Employee Assistance Program (EAP).
  • 🏆 Recognition Platform – Acknowledge and appreciate outstanding employee contributions.
  • 🌈 Diversity, Equity, and Inclusion Initiatives – Join a workplace committed to fostering diversity and inclusion.
  • 📚 Tuition Reimbursement – Invest in your ongoing education and development.
  • 🎁 Employee Perks and Discounts – Additional benefits and discounts exclusively for employees.
  • 🌟 Maximus Wellness Program and Resources – Access a range of wellness programs and resources tailored to your needs.
  • 📚 Professional Development Opportunities-Participate in training programs, workshops, and conferences.
  • 📝Licensures and Certifications-Maximus assumes the expenses associated with renewing licenses and certifications for its employees.

Essential Duties and Responsibilities:

  • Review requests for services including admission, discharges and continued stays for adherence to clinical criteria, state and federal policy, and related requirements.
  • Issue approvals, denials or recommendations based on contract requirements.
  • Identify need for additional clinical documentation or consultation.
  • Complete documentation of activities within contract systems.
  • Communicate with providers, individuals and their designees, or state workers as required.
  • Performs other related duties as assigned.
  • Review appeal requests and all ancillary documentation to recommend a clinical determination using specific clinical criteria
  • After state approval, participate in phone-based hearings as a witness for the State of Tennessee .

Minimum Requirements

  • Current Registered Nurse (RN) license valid in the state of practice is required
  • High School Degree or equivalent required
  • Minimum 2 years of clinical experience required
  • Associate's Degree
  • Valid RN license in Tennessee or a compact license with Tennessee designated as the primary state
  • 5 years of experience in acute care or physical rehabilitation
  • 1-2 years of experience in mental health or working with individuals with intellectual and developmental disabilities (IDD)

Preferred:

  • Prior experience in utilization management
  • Prior experience with chart reviews and audits

Home Office Requirements

  • Maximus provides company-issued computer equipment
  • Reliable high-speed internet service
  • Minimum 20 Mpbs download speeds/50 Mpbs for shared internet connectivity
  • Minimum 5 Mpbs upload speeds

Clinical Review Specialist - Registered Nurse (Remote in Tennessee) ID-8033

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