Consultant - Appeals

at  MAXIMUS Services LLC

Description & Requirements
Maximus is looking for a Consultant Appeals.
This is a full-time, fully remote position.

Essential Duties and Responsibilities:

• Subject matter expert for the most complex Appeals and Hearings cases.
• 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.
• 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.
• Familiarity with medical terminology and/or medical record review required.
• Familiarity with California health care law/Knox Keene Act and managed health care preferred.
• Familiarity with California health care law/Knox Keene Act and managed health care preferred.

HOME OFFICE REQUIREMENTS:

• Hardwired internet (ethernet) connection.
• Internet download speed of 25mbps single upload or higher required (you can test this by going to www.speedtst.net).
• Private work area and adequate power source.
• Video calls may be requested on occasion. Proper background and attire is required.

MINIMUM REQUIREMENTS:

• Juris Doctorate Required.
• Familiarity with medical terminology and/or medical record review required.

Minimum Requirements

• Bachelor’s degree in relevant field of study and 3+ years of relevant professional experience required, or equivalent combination of education and experience.

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

• Subject matter expert for the most complex Appeals and Hearings cases.
• 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.
• 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.
• Familiarity with medical terminology and/or medical record review required.
• Familiarity with California health care law/Knox Keene Act and managed health care preferred.
• Familiarity with California health care law/Knox Keene Act and managed health care preferred