Clinical Reviewer LPN - (Remote)

Description & Requirements

Maximus is seeking a Clinical Reviewer (LPN) supporting the Colorado HMA (Health Maintenance Activities) Review Program. This role requires completion of desk based clinical reviews to determine appropriateness of recommended services, supports program goals and service level agreements (SLAs). The reviewer must participate in all required trainings and meetings, in addition to other tasks as required by their supervisor. Work Schedule: This position is scheduled Monday through Friday from 8:00 a.m. to 5:00 p.m. Mountain Time with some weekend coverage required based on business needs. 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. - 📚 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 admissions, discharges, and continued stays for adherence to clinical criteria, state and federal policy, and contract requirements involving broad clinical complexity and variability; apply subject matter expertise to ensure consistency and drive quality outcomes; and escalate exceptions to policies. - Issue approvals, denials, or recommendations based on contract requirements; ensure quality, consistency, and adherence to clinical and regulatory standards across cases. - Identify the need for additional clinical documentation or consultation and analyze information gaps to support accurate and timely determinations. - Complete accurate documentation of review activities within contract systems. - Communicate and collaborate with providers, individuals and their designees, state workers, and external stakeholders to clarify requirements, resolve issues, and support program outcomes. - Provide guidance, coaching, training and quality review for team members; identify opportunities to improve review processes and consistency. - May meet with external clients to confirm and update clinical guidelines that must be followed internally. - May write high-quality, fully substantiated clinical determination reports by synthesizing assessment findings, interview data, and supporting documentation, including completing the summary of findings.

- Specific clinical license and experience requirements based on contract requirements.

- Associate degree in Nursing - An active LPN license in the state of Colorado or a compact license is required - Minimum 2 years of experience working with people with complex disabilities, including pediatric and geriatric populations - Familiarity with Home and Community Based Services waivers (HCBS) - Proficiency in Microsoft Office applications Preferred Requirements: - Prior experience