Director - Appeals (Health Insurance, Disability, Workers Compensation)

Description & Requirements

Maximus is currently hiring for a Director - Appeals (Health Insurance, Disability, Workers Compensation) to join our team.

This is a remote opportunity and contingent upon award of contract.

The Director will be responsible for managing a portfolio of programs.



*

*

*Please note that this position is contingent upon contract award

*

*

*

Essential Duties and Responsibilities:
- Act as the primary contact for the state client
- Ensure program operations are in compliance with all applicable requirements of the contract, as well as State and federal regulations.
- Ensure goals and objectives are established by Project Manager that support the overall Project strategies.
- Oversee all project administrative operations including budget, financial controls, and human resources.
- Plan, develop and schedule priorities for achieving operational and performance goals.
- Review management, productivity, and financial reports and studies to ensure program objectives are met.
- Participate in internal audits, research studies, forecasts, and modeling exercises to support Project direction and guidance.
- Manage operational managers, to include performance appraisals, mentoring, and professional/development guidance.
- Demonstrate a high level of dedication and proactive leadership in meeting corporate goals and program objectives.
- Perform other duties as assigned by management.

- Medical Necessity Reviews: Conduct reviews of clinical services to determine medical necessity based on established guidelines and criteria.
- Compliance: Ensure all reviews comply with state-specific workers' compensation regulations and standards
- Case Management: Collaborate with healthcare providers, claims adjusters, and other stakeholders to manage cases effectively.
- Documentation: Maintain accurate and detailed records of all reviews and decisions made.
- Communication: Provide clear and concise communication to healthcare providers regarding review outcomes and recommendations.
- Education: Educate providers and staff on workers' compensation guidelines and utilization review processes.
- Quality Assurance: Participate in quality assurance activities to ensure the integrity and accuracy of the review process.

Minimum Requirements

- Bachelor's degree in relevant field of study and 10+ years of relevant professional experience required.

- BA, BS, Registered Nurse (RN) with a valid nursing license or Masters or JD.
- Experience in workers' compensation, utilization review, or related fields preferred
- Strong analytical, communication, and organizational skills.

Proficiency in medical terminology and clinical guidelines.
- Relevant certifications such as CCM, COHN, or CRRN may be required.

- Knowledge of workers' compensation laws and regulations

- Experience with New York State Workers' Compensation Guidelines (MTGs), New York State Workers' Compensation Board Drug Formulary (Formulary), New York State Workers' Compensation Fee Schedules ...