Manager - Client Policy Ops Support

Description & Requirements

This role is primarily responsible for arbitrating payment disputes between providers, facilities, or providers of air ambulance services, and group health plans, health insurance issuers/carriers.

It is essential to remain neutral when analyzing the materials provided, and to be able to write a concise determination in a short period of time.

Essential Duties and Responsibilities:

- Provide legal research, guidance, advice, leadership, and training to project staff, ensuring compliance with all project and client policies/procedures, laws, and regulations.

- Interact with the client regarding case decisions.

- Guide teams to ensure all major client/legal requirements are met and relevant documents are captured accurately.

- Provide self-directed legal support to the project leadership.

- Process and resolve high profile and complex cases.

- Manage direct reports, including hiring, setting monthly individual/team goals, and evaluating employee performance.

- Reviews all credible documentation received from involved parties regarding their proposed payment amount and renders an independent payment determination, by selecting one of the two submitted offers with rationale behind determination.

- Review eligibility determinations based on Federal and State guidelines.

- Draft and review payment determination decisions.

- Create policy documentation, processes, procedures, and job aids for administrative staff.

- Serve as a subject matter expert regarding surprising billing regulations.

- Communicate with project staff regarding regulatory/legal questions, opinions, and interpretations.

- Act as an advisor on regulatory/legal issues involving compliance.

- Draft email responses to payment dispute questions or concerns from the disputing parties.

- Coordinate with internal counsel for litigation and legal matters, as needed.

- Interpret applicable regulations and policies associated with case to determine recommendation.

- Ensure solutions are consistent with organizational objectives.

- Juris Doctor from an accredited law school.

Licensed attorney, preferred.

- Familiar with Surprise Billing regulations, rules, and policies; and claims Arbitration procedures/practices.

- Excellent organizational, interpersonal, written, and communication skills.

- Ability to work as a team member, as well as independently.

- Work across multiple systems, such as SharePoint, Salesforce, and Microsoft Office products.

- Healthcare Law experience, highly preferred.

- Litigation experience, preferred.

- Legal writing experience, preferred.

- Medical coding experience, preferred.

Minimum Requirements:

- JD preferred

- 3-5 years of relevant professional experience required.

- Equivalent combination of education and experience considered in lieu of degree.

- Minimum of 3-5 years of arbitrating or adjudicating medical claims.

- Ability to perform comfortably in a fast-paced, deadline-orientated work environment....