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Senior Consultant - Appeals The candidate oversees the appeals process for many state projects and a few federal projects. Analyzes and renders coverage dispute reconsiderations for state and federal projects. Ensures coverage dispute reconsideration meet applicable quality standards; performs quality assurance reviews. Collaborates with nurses and clinical/medical experts in order to produce a high quality review. Researches, analyzes and applies state and federal regulations. Stays current with regulations that apply to all assigned projects. Reviews, edits and critiques reviews. Documents and updates workflows and best practices. Facilitates/leads conference calls with customers. Participates in hearings to explain and defend decisions. Ensures contractual requirements are met. 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 of experience in law office or applicable experience. Proven experience in working in fast paced environment is a plus. Must have the ability to conduct comprehensive research in law and health policy. Excellent organizational, interpersonal, written, and verbal communication skills are required. Experience with communicating directly with government agencies desired. Should have proficiency in Microsoft Word, Excel, Visio and Internet research. Litigation experience is a plus. Legal writing experience is preferred. Advanced health-related degree is desired. 5+ years of experience interpreting healthcare regulations is desired.
Requisition ID: 2018-31859
Company infoHiring Coordinator