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Senior Consultant - Appeals The candidate will assist in legal analysis and provides coaching and procedural instructions for variety of staff as requested. Will serve as the Policy Subject Matter Expert (SME) for the Part D QIC Project. Manage Administrative Law Judge (ALJ) activities for project assigned. Analyze and render coverage dispute reconsiderations for Medicare’s Qualified Independent Contractor. Ensures coverage dispute reconsideration meet applicable quality standards; performs quality assurance reviews of certain reconsideration determinations. Reviews and Updates Part D specific Policy materials as appropriate and documents; communicates across the department where appropriate. Represents the QIC Part D on the QIC Change Control Committee. Participates in ALJ (Administrative Law Judge) hearings to explain and defend reconsideration decisions; both as a party and non-party; processes reconsideration reopening, vacated dismissals and ALJ remands. Responds to outside inquiries of concerns regarding decided reconsidered determinations. Performs special projects not related to a specific case such as general legal research; general medical research, drafting proposal sections or acting as a liaison for a specific project. Performs other duties as assigned by management. Must have Juris Doctor degree from an accredited law school; Must be a licensed attorney. Should have 2-3 years’ experience in law office or applicable experience. Ability to conduct comprehensive research in law and health policy is required. Excellent organizational, interpersonal, written, and verbal communication skills is needed. Proficiency in Microsoft Word and Excel and Internet research is must. Litigation experience is preferred. Legal writing experience is desired. Advanced health-related degree is a plus. 5+ years’ experience interpreting and applying Medicare regulations is helpful.
Requisition ID: 2018-30160
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