Appeal Officer / Health Care Attorney (Remote)

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

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 i...