Senior Quality Assurance Specialist - RN: Driving Excellence in Healthcare Appeals (Remote Opportunity)

Join MAXIMUS: Empowering Government Programs and Transforming Lives

At MAXIMUS, a leading provider of business process management and technology solutions, we're on a mission to help government agencies deliver high-quality services to citizens worldwide. With a rich history spanning over four decades, we've established ourselves as a trusted partner to governments across the globe, driving improved outcomes, productivity, and efficiency in health and human services programs. As a Senior Quality Assurance Specialist - RN, you'll play a critical role in ensuring the accuracy and quality of our healthcare appeals processes, driving continuous improvement, and contributing to the success of our clients.

About the Role

We're seeking an experienced Senior Quality Assurance Specialist - RN to join our team on a remote basis. As a key member of our Quality Assurance team, you'll be responsible for evaluating the quality of healthcare appeals decisions, analyzing results, and driving process improvements. Your clinical expertise, combined with your analytical skills and attention to detail, will enable you to make a meaningful impact on our operations and contribute to the delivery of exceptional services to our clients.

Key Responsibilities

• Review completed Part A West reconsideration appeal cases to determine the accuracy of summarized facts and assessment of issues involved in the case
• Make internal quality determinations on the result of State and Federal case review decisions, ensuring compliance with relevant laws, regulations, and policies
• Research complex issues using federal and state laws, regulations, and agency policies to inform quality assurance decisions
• Ensure accurate and timely entry of quality review data into related tracking systems, maintaining data integrity and supporting process improvements
• Provide feedback and education to adjudication staff, promoting professional development and enhancing overall quality
• Participate in collaboration meetings with project leadership, contributing to strategic discussions and driving business outcomes
• Assist with special projects, such as general legal research, medical research, and drafting proposal sections, as needed
• Perform other duties as assigned by management, demonstrating flexibility and a commitment to team success

Essential Qualifications

To succeed in this role, you'll need:

• An active RN license in the state you're hired in
• A four-year nursing degree (preferred)
• At least two years of clinical experience in general medical care (preferred)
• Clinical Adjudication experience (required)
• High proficiency in Microsoft Word and the ability to quickly learn multiple database systems
• Knowledge of health regulations, guidelines, and coverage issues
• Excellent organizational, written, and verbal communication skills
• The ability to work effectively in a fast-paced, deadline-oriented environment
• A strong team player with the ability to work independently

Preferred Qualifications

• A Bachelor's degree with 5+ years of experience (or equivalent)
• An advanced degree or professional designation (preferred)
• Knowledge of statistical terminology and use of statistics
• Familiarity with quality management and/or quality improvement methods, such as ISO, Lean Six Sigma, or Six Sigma

What We Offer

At MAXIMUS, we're committed to providing a rewarding and challenging work environment that supports your career growth and personal well-being. As a Senior Quality Assurance Specialist - RN, you'll enjoy:

• A competitive salary, with a range of $57,300 to $109,400 per year, depending on your experience and qualifications
• A comprehensive benefits package, including health insurance coverage, life and disability insurance, and a retirement savings plan
• Paid holidays and paid time off, allowing you to recharge and maintain a healthy work-life balance
• Opportunities for professional development and career growth, with a focus on promoting from within
• A dynamic and supportive work environment, with a team of experienced professionals who are passionate about delivering exceptional results

Our Culture and Values

At MAXIMUS, we're proud of our culture and values, which are centered around:

• Helping Government Serve the People: We're dedicated to making a positive impact on the lives of citizens worldwide.
• Innovation and Excellence: We strive for continuous improvement, embracing new ideas and best practices to drive business success.
• Integrity and Ethics: We operate with the highest level of integrity, adhering to our code of ethics and promoting a culture of transparency and accountability.
• Diversity and Inclusion: We value diversity and promote an inclusive work environment, recognizing that different perspectives and experiences are essential to our success.

Why Join Us?

If you're a motivated and experienced Senior Quality Assurance Specialist - RN looking for a challenging and rewarding role, we encourage you to apply. At MAXIMUS, you'll have the opportunity to:

• Drive business outcomes and contribute to the success of our clients
• Develop your skills and expertise in a dynamic and supportive work environment
• Enjoy a competitive salary and benefits package, with opportunities for career growth and professional development
• Be part of a team that is passionate about making a positive impact on the lives of citizens worldwide

Ready to take the next step in your career? Apply now to join our team as a Senior Quality Assurance Specialist - RN and discover a rewarding and challenging opportunity that aligns with your skills and experience.