Clinical Nurse Consultant

MAXIMUS • Dover, DE • 1d ago

Maximus is currently hiring for a Clinical Nurse Consultant to join our Federal Exchange Review Process (FERP) team. This is a remote opportunity. The Consultant manages the end-to-end medical review process, ensuring cases are accurately assessed, assigned to the appropriate clinical specialty reviewer, and completed within established timelines. This role collaborates with healthcare providers, prepares case summaries and medical necessity documentation, and supports quality assurance to ensure timely and compliant review decisions.

This position will require a Federal Suitability Clearance post-hire as mandated by the client.

Essential Duties and Responsibilities:

Responsible for reviewing favorable and partially favorable determinations in accordance with applicable regulations.

Render determinations for cases assigned.

Resolve all other technical issues within reconsideration assigned.

Review cases or sites assigned to determine and summarize facts and assess any issues identified.

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.

Perform other duties as assigned by management.

'- Review medical records and identify the appropriate clinical specialty required for review.

Conduct outreach to qualified reviewers.

Assign cases in Salesforce.

Prepare case files and complete the accompanying medical review form.

Submit complete case files to panelists through Axway.

Receive completed reviews from panelists and verify cited references.

Prepare draft decisions using established templates.

Minimum Requirements

'- Bachelor's degree with 3 - 5 years of experience, OR Associate's degree with 5-7 years of experience.

'- Ability to work a schedule between the hours of 9:00am - 6:00pm EST Monday - Friday.

Flexibility to work extended hours or weekends as business needs require.

Ability to pass a Federal Suitability Clearance.

Preferred Skills and Qualifications:

Valid, active LPN or RN license.

Experience working with Salesforce and/or Axway.

Experience reviewing medical records and/or health plan regulations.

Please note: For this position Maximus will provide equipment to use.

Home Office Requirements:

Internet speed of 25mbps 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 Category 5 or 6 ethernet patch cable to the home router

Private and secure work area and adequate power source

Must currently and permanently reside in the Continental US

Must have a smartphone which will be required to log into Maximus systems

Maximus is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, age, national origin, disability, veteran status, genetic information and other legally protected characteristics.

Minimum Salary

$59,000

Maximum Salary

$65,000

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