Sr Specialist - QA, RN (remote opportunity)

Job Description SummaryThe Sr. Specialist Quality Assurance is responsible for completing quality evaluations as part of the quality management plan and analyzing results to drive continuous improvement.

• Review completed Part A West reconsideration appeal cases to determine the accuracy of the summarized facts and assessment of issues involved in the case
• Make an internal quality determination on the result of State and Federal case review decisions
• Research issues using federal law, state law, regulations, and relevant agency policies
• Ensure quality review is accurate and enter data into related quality tracking system
• Provide feedback and education to adjudication staff
• Participate in collaboration meetings with project leadership
• Assist project with adjudication of appeals and/or decision letter quality reviews as needed
• 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
• RN with an active license in state hired required; RN and four-year nursing degree preferred
• At least two (2) years' clinical experience with general medical care of patients preferred
• Clinical Adjudication experience required
• Highly proficient in Microsoft Word and able to quickly learn multiple database systems and comfortably manage multiple screens at the same time
• Knowledge of health regulations, guidelines and coverage issues
• Knowledge of statistical terminology and use of statistics preferred
• Knowledge of quality management and/or quality improvement methods such as ISO, Lean Six Sigma or Six Sigma preferred
• Excellent organizational, written, and verbal communication skills
• Ability to perform comfortably in a fast-paced, deadline-oriented work environment
• Ability to work as a team member, as well as independently

Job Summary

• Bachelor's degree with 5+ years of experience.
• Advanced degree or professional designation preferred.
• Develops solutions to a variety of complex problems.
• Work requires considerable judgment and initiative.
• Exerts some influence on the overall objectives and long-range goals of the organization.

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 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. Posted Max USD $109,400.00/Yr. Posted Min USD $57,300.00/Yr. Apply Job!