Sr. Consultant - Arbitration

Description & Requirements

Maximus is currently hiring for a Sr.

Consultant - Arbitration to join our State Arbitration team.

This is a remote opportunity.

The Sr.

Consultant - Arbitration is responsible for providing a quality review of payment determination letters in their final stages before being sent out to the client.

In addition to conducting these quality checks, the Sr.

Consultant may also be asked to assist in writing payment determination letters when needed.

The Sr.

Consultant must remain neutral when analyzing the materials provided, and must be able to write a concise determination in a short period of time to meet deadlines.

Essential Duties and Responsibilities:

- Review cases to determine and summarize facts of each case assigned and assess issues involved in the case.

- Research issues using federal law, federal regulations, relevant contract law and other sources as defined by the client contract.

- Review plan contracts and other relevant information; make a decision as to whether an enrollee is entitled to benefits in cases involving contractual disputes.

- Communicate the determination in a clearly written format.

- Exercise independent judgment to ensure determination is accurate, well supported and defensible; take appropriate action as required.

- Research issues using federal law, federal regulations, relevant contract law and other sources as defined by the client contract.

- Acquire all necessary information involving cases and render final determination based on the information provided by the appellant.

- Assist with training and mentoring of new staff members.

- Manage highly complex case files.

- Support Appeals Manager with facilitating quality assurance initiatives and sharing knowledge with other team members.

- Serve as point of contact to address escalated issues in Appeals Manager's absence.

- Perform other duties as may be assigned by management.

- 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 rational behind determination.

- Review eligibility determinations based on State No Surprise Act (NSA) guidelines.

- Draft and review payment determination decisions.

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

- Communicate with project staff regarding policy questions, opinions, and interpretations.

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

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

- Ensure solutions are consistent with organizational objectives.

Minimum Requirements

- Bachelor's degree in relevant field of study and 5+ years of relevant professional experience required, or equivalent combination of education and experience.
- Advanced degree preferred.

- Minimum of 5 years of arbitrating or a...