This position will support clinical consulting service programs for state clients with long-term relationships with Maximus - including the California Department of Managed Health Care and California Department of Insurance. Programs cover multiple subject areas including benefit coverage disputes, billing disputes, and medical consulting. This position involves purely transactional work. It does not involve any litigation.

This is an exciting opportunity to join our team!

The Appeal Officer (Health Care Attorney) will conduct a careful analysis of medical records and expert reviewer findings to assess eligibility for coverage and ensure the appropriate determination is reached.

Primary Responsibilities:

• Review cases to identify and summarize key facts of each case and assess medical and legal issues involved in the case
• Research issues using California law, California regulations, current peer-reviewed medical literature, clinical guidelines, and other sources as defined by the client contract
• Determine the adequacy of medical records and request relevant medical records as needed
• Communicate the determination in a succinct written format
• Exercise independent judgment to ensure determination is accurate, well-supported, and defensible.

Minimum Qualifications:

• JD Required
• Significant experience in Health Care Appeals, Pharmacy Claims, Behavioral Health Treatment, or other related fields
• Ability to successfully execute many complex tasks simultaneously and prioritize tasks according to urgency
• Ability to respond to the needs of outside contacts
• Working knowledge and use of PC, claim adjudication, MS Word and Excel software, and appeals system software
• Must be able to work as a part of a team as well as independently, and promote positive company relations
• Excellent organizational, interpersonal, written, and verbal communication skills
• Familiarity with medical terminology and/or medical record review required
• Familiarity with California health care law/Knox Keene Act and managed health care preferred

Remote Assignment Requirements:

• Conduct daily activities and supervisor communications as if the employee were in an office location
• Must be accessible by phone, e-mail, IM, or voice mail within a reasonable time period during the agreed-upon work schedule
• Check e-mail, voice mail, and IM for updates throughout the agreed-upon work schedule timeframe
• Other members of the Remote Worker’s family and visitors to the Remote Worker’s home may not use Maximus equipment
• Make appropriate work arrangements that maintain separation between the employee’s private life and business activities
• An established and demonstrated safe and quiet home work environment (as defined by the Remote Worker PI Policy and the Remote Worker Privacy and Security Checklist)
• Ability to use and maintain reliable internet service (Broadband/Cable internet is recommended with 80 megabits download capability)

Full Benefits to include: PTO/UTO 401K Medical/Dental options Competitive Wages

As a leading strategic partner to governments across the globe, Maximus helps improve the delivery of public services amid complex technology, health, economic, environmental, and social challenges. With a deep understanding of program service delivery, acute insights that achieve operational excellence, and an extensive awareness of the needs of the people being served, our employees advance the critical missions of our partners. Maximus delivers innovative business process management, impactful consulting services, and technology solutions that provide improved outcomes for the public and higher levels of productivity and efficiency of government-sponsored programs.