Appeal Officer / Health Care Attorney (Remote) Maximus Federal (JD Required)

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)

Job Summary

Essential Duties and Responsibilities:

- Evaluate data associated with complex customer issues to determine compliance or to make exceptions to applicable regulations and policies; may require contacting the customer to obtain additional information or clarify actions pertinent to the case.

- Research laws and regulations and apply rules to case-specific situations.

- Provide complaint resolution to customers verbally or in writing, utilizing discretion.

- May attend hearings and/or management meetings to discuss cases.

Minimum Requirements:

- Bachelor's Degree from an accredited college or university.

- 3-5 years of related experience.

Education and Experience Requirements

- Must be willing to work pacific time zone schedule.

- Must be licensed to practice law in the United States.

MAXIMUS Introduction

Since 1975, Maximus has operated under its founding mission of Helping Government Serve the People, enabling citizens around the globe to successfully engage with their governments at all levels and across a variety of health and human services programs. Maximus delivers innovative business process management and technology solutions that contribute to improved outcomes for citizens and higher levels of productivity, accuracy, accountability and efficiency of government-sponsored programs. With more than 30,000 employees worldwide, Maximus is a proud partner to government agencies in the United States, Australia, Canada, Saudi Arabia, Singapore and the United Kingdom. For more information, visit https://www.maximus.com.

EEO Statement

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.

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.

Posted Max

USD $85,000.00/Yr.

Posted Min

USD $42,400.00/Yr.

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.