Job Details

Consultant Appeals

Company name

Maximus

Organization Type

In-House

Job Type

Attorney

Valid Through

Oct 24,2019

Posted on

Jul 11,2019

Years of Experience

Min 2 yrs required

Location

Folsom, CA, United States

Employment Type

Full-time

Industry

Legal
Practice Area
Health Care >> Health Care
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Consultant - Appeals
The candidate will support clinical consulting service programs across multiple state clients including the California Department of Managed Health Care and California Department of Health Care Services. Programs cover multiple subject areas including billing disputes, fraud and abuse, pharmacy formulary review, development of average contract rate methodology and medical consulting. Review cases to determine and summarize facts of each case assigned and assesses 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 and then 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 and 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 information and render final determination based on the information provided by the appellant. Perform other duties as may be assigned by Management.

Qualification and Experience

The candidate should have Bachelor’s degree from an accredited college or university. JD degree required. 2+ years’ experience in Health Care Appeals, Pharmacy Claims or other related fields required. Must have working knowledge and use of PC, claim adjudication, MS Word and Excel software, and appeals system software. Must have Bachelor's degree with 3-5 years of experience consulting within designated function.

Additional info

Requisition ID 2019-42233

Company info

Hiring Coordinator
Maximus
625 Coolidge Dr
Folsom, CA 95630

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