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Senior Appeals Specialist

2 months ago

Montgomery, Alabama, United States MAXIMUS Full time
About the Role

Maximus is seeking a highly skilled and experienced Senior Appeals Specialist to join our team. As a key member of our appeals team, you will be responsible for evaluating complex customer issues, researching laws and regulations, and providing complaint resolution to customers.

Key Responsibilities
  • Subject Matter Expertise: Serve as a subject matter expert for complex Appeals and Hearings cases, evaluating data and determining compliance or making exceptions to applicable regulations and policies.
  • Case Evaluation: Evaluate data associated with complex customer issues, research laws and regulations, and apply rules to casespecific situations.
  • Complaint Resolution: Provide complaint resolution to customers verbally or in writing, utilizing discretion and exercising independent judgment to ensure determination is accurate, well supported, and defensible.
  • Case Management: Review cases to identify and summarize key facts of each case, assess medical and legal issues involved, and communicate the determination in a succinct written format.
  • Research and Analysis: Research issues using California law, California regulations, current peer-reviewed medical literature, clinical guidelines, and other sources as defined by the client contract.
  • Medical Record Review: Determine the adequacy of medical records and request relevant medical records as needed.
Requirements
  • Education: Juris Doctorate Required.
  • Experience: Bachelor's degree in a relevant field of study and 3+ years of relevant professional experience required, or equivalent combination of education and experience.
  • 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.
Work Environment

This is a full-time, fully remote position. You will need a hardwired internet connection, internet download speed of 25mbps single upload or higher, a private work area, and adequate power source. Video calls may be requested on occasion.