Requirements Description & Requirements Maximus is hiring a Clinical Review Specialist - Registered Nurse to join our Audit and Appeals team! In this role, you will evaluate submitted appeals and make decisions based on clinical evidence. If you're passionate about making a positive impact in healthcare and have a keen eye for detail , apply today! This is a remote position, and candidates must reside in Tennessee. 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. ?? Diversity, Equity, and Inclusion Initiatives Join a workplace committed to fostering diversity and inclusion. ?? 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 admission, discharges and continued stays for adherence to clinical criteria, state and federal policy, and related requirements. Issue approvals, denials or recommendations based on contract requirements. Identify need for additional clinical documentation or consultation. Complete documentation of activities within contract systems. Communicate with providers, individuals and their designees, or state workers as required. Performs other related duties as assigned. Review appeal requests and all ancillary documentation to recommend a clinical determination using specific clinical criteria After state approval, participate in phone-based hearings as a witness for the State of Tennessee . Minimum Requirements Current Registered Nurse (RN) license valid in the state of practice is required High School Degree or equivalent required Minimum 2 years of clinical experience required Associate's Degree Valid RN license in Tennessee or a compact license with Tennessee designated as the primary state 5 years of experience in acute care or physical rehabilitation 1-2 years of experience in mental health or working with individuals with intellectual and developmental disabilities (IDD) Preferred: Prior experience in utilization management Prior experience with chart reviews and audits Home Office Requirements Maximus provides company-issued computer equipment Reliable high-speed internet service Minimum 20 Mpbs download speeds/50 Mpbs for shared internet connectivity Minimum 5 Mpbs upload speeds 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. Were 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. Minimum Salary $ 28.00 Maximum Salary $ 35.00 Apply Job!