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.  

- Review and provide independent medical reviews for prior authorization requests for relating to Workers’ Compensation benefits (WC), Disability benefits (DB), Paid Family Leave (PFL) benefits, Volunteer Firefighters’ benefits, and Volunteer Ambulance Workers’ benefits.- Evaluate Level 3 prior authorization requests (PARs) for medical services and goods including but not limited to all PAR types (Medication, Confirmation, Variance, Special Services, Durable Medical Equipment), all New York State Workers’ Compensation Medical Treatment Guidelines and Drug Formulary criteria for all medical services, medications, medical devices contemplated therein, or requests for variances for medical treatment not addressed or recommended.- 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 that is clear, professional and grammatically correct.- Ability to perform comfortably in a fast-paced, production and deadline-oriented work environment.- Provide written clinical rationales for Workers Compensation cases.- Review, organize and identify all medical records provided for prior authorization requests (PAR) for assigned 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 clinical research, general medical research, etc.- Become a subject matter expert (SME) using job aides and learning tools.- Work on special projects as assigned.- Other duties as assigned by management.

Minimum Requirements
- Bachelor's degree with 3-5 years of experience consulting within designated function. - Current Registered Nurse (RN) license valid in the state of practice required.- Experience in state workers compensation required. Preferably, in the state of New York.

Preferred Skills and Qualifications:- Possess ample medical knowledge and experience with medical terminology, ICD-9/10 Codes, Current Procedure Terminology Codes (CPT) codes- Medical/Utilization Review experience.- 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.
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 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. 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.