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Physician Medical Reviewer (Remote Opportunity) in Town of Pittsford, NY at Maximus, Inc.

Date Posted: 3/17/2018

Job Snapshot

Job Description

MAXIMUS is a leading operator of government health and human services programs and has partnered with state, federal and local governments to provide critical, high quality health and human service programs to a diverse array of communities. Operating under MAXIMUS’s founding mission of Helping Government Serve the People® since 1975, MAXIMUS Federal Services is entirely focused on helping government agencies run programs cost-effectively and serve program constituents with improved outcomes. By being a responsible steward for government programs, we help the federal government deliver on its promises through our people, process and technology. Our focus is always on outcomes and results that connect citizens more effectively with government services.

The Centers for Medicare and Medicaid Services (CMS) second level appeal Qualified Independent Contractor (QIC) Durable Medical Equipment (DME) project is the program that this position will support. The physician medical reviewer is responsible for medical review decisions rendered through the appeal process.

The Physician Reviewer is responsible for reviewing clinical data and make a reconsideration decision based on the appropriate coverage rules and guidance. This position also provides the medical opinion to be used in resolving Medicare DME Coverage disputes.


  • Apply CMS to coverage rules and guidelines to make medical necessity determinations at the reconsideration level of appeal
  • Review clinical data for the purpose of making medical necessity reconsideration decisions applying coverage rules and guidance for DME appeals
  • Participate in meetings with client, Medical Director or other interested parties to discuss existing and newly developed coverage issues
  • Identify and apply current medical evidence and standards of care to utilization, appeal or quality-oriented chart review and to maintain high levels of chart review productivity
  • Participate in the recruitment, interviewing, training members of internal and external contracted clinical personnel
  • Participate in continual process improvement efforts resulting in high production while maintaining high quality for utilization and medical necessity review

The Ideal Candidate will Possess the Following Additional Education and Experience
  • Doctor of Medicine or Osteopathy currently licensed in a US State, with Board certification in one of more specialties recognized by the ABMS (American Board of Medical Specialties) or AOBM (American Osteopathic Board of Medicine)
  • At least five (5) years, post Board certification, experience in direct patient care, following the completion of a residency program, required
  • Primary care or physical medicine and rehabilitation experience preferred
  • Ability to pass stringent credentialing based upon URAC/NCQA type standards
  • Knowledge of Medicare programs, particularly coverage and payment rules
  • Technology experience with programs, i.e., Microsoft Office (Word and Excel) and ability to research utilizing the Internet preferred, including web based portals

Preferred skills

  • DME review experience strongly preferred
  • At least two (2) or more years’ experience as a reviewer for a Medicare Contractor (e.g., Fiscal Intermediary, Carrier, etc.) or health insurance company and intimate knowledge of Medicare coverage and reimbursement policies, and related issues
  • At least two (2) years’ experience medical management functions, including “evidence based medicine” research or application, strongly preferred

Additional Requirements as per Contract/Client:

  • United States Citizenship

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.