Clinical Reviewer RN (Remote in TN)

Maximus is seeking a Clinical Reviewer (Registered Nurse) to support the Tennessee (TN) Appeals area of the contract. In this role, the RN Clinical Reviewer is responsible for reviewing clinical cases, applying nursing judgment and regulatory guidelines, and ensuring each case is accurately assessed and routed to the appropriate department or escalated as needed. This position plays a critical role in maintaining compliance, supporting timely appeal resolutions, and ensuring high-quality, clinically sound decision-making. About the Program: Tennessee Long-Term Services and Supports (TN LTSS) refers to a coordinated system of programs and services designed to assist individuals who have chronic illnesses, disabilities, or functional limitations and need ongoing support to live as independently and safely as possible. TN LTSS includes a range of home- and community-based services (HCBS) and institutional care options that help individuals with activities of daily living, medical needs, and personal care, while prioritizing care in the least restrictive setting. The program supports older adults and individuals with physical, intellectual, or developmental disabilities through person-centered planning that promotes dignity, independence, and quality of life. 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 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.