SUMMARY

The incumbent monitors and reports on all mediation and appeal requested by applicants and beneficiaries whose clinical assessment results in a denial or reduction in health care services.

ESSENTIAL FUNCTIONS

1. Processes correspondence, appeals, program reviews, reports and other requests.
2. Serves as a content knowledge expert regarding business rules of the project; review/research mediation and appeals cases.
3. Works closely with the Clinical Director and Program Managers in assisting with resolving difficult and complex cases.
4. Works closely with the Clinical Director and Program Managers to investigate issues raised by clients in their correspondence, appeals and requests.
5. Creates letter requests in response to applicant inquiries regarding case status, appeals, and other written requests.
6. Works closely with team to accurately adjudicate appeals and determine the outcome of the case.
7. Participate in mediation and appeals hearings as requested by
8. Provides the Clinical Director and Program Managers with updates on all issues regarding quality, training, policy & procedures.
9. Meets all standards established for this position as outlined in the attached performance criteria.
10. Performs other duties, as necessary or assigned by the manager.

Knowledge, Skills & Abilities

• Experience handling inquires, complaints and appeals
• Experience in level of care/service eligibility determinations in health, human services or a related field
• Excellent organizational, interpersonal, written, and verbal communication skills
• Excellent analytical and complex reasoning skills
• Ability to perform all job duties in compliance with Person First standards, HIPAA guidelines, and company confidentiality policies
• Ability to multitask effectively while performing job duties, including ability to prioritize tasks and ensuring all voice mail and email messages are returned within six business hours of receipt
• Ability to perform comfortably in a fast-paced, deadline-oriented work environment
• Ability to successfully execute many complex tasks simultaneously
• Ability to work as a team member, as well as independently
• Intermediate skill with word processing, spreadsheet, presentation, and publishing software (Microsoft Word, Excel, PowerPoint, Publisher, and Visio strongly preferred)

Education

The job requires a Bachelor’s degree. Experience working with individuals with chronic medical conditions and/or cognitive impairment preferred. Experience making level of care determinations also preferred.

Experience

The job requires at least three (3) years of experience within a healthcare, mental health, or long-term care setting. Experience managing enterprise-wide quality assurance and improvement strongly preferred.

• Bachelor's degree with 3+ years of experience.
• May have additional training or education in area of specialization.
• Develops solutions to a variety of problems of moderate scope & complexity.
• General application of concepts & principles.
• Contributes to the completion of organizational projects & goals.
• Frequent use and general knowledge of industry practices, techniques, and standards.
• Applies knowledge and skills to complete a wide range of tasks.
• Communicates on complex or sensitive issues or drafts such responses for supervisor or manager.

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.

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.