Description & Requirements
This role is primarily responsible for arbitrating/deciding payment disputes between health care providers, health care facilities, or providers of air ambulance services, and group health plans, or health insurance issuers. The arbiter 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 rationale behind determination.
• Review eligibility determinations based on State No Surprise Act (NSA) guidelines.
• Draft and review payment determination decisions.
• Create policy documentation, processes, procedures, and job aids for administrative staff as needed.
• 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.
• Bachelor's degree in related field.
• 5+ years of relevant professional experience required; e quivalent combination of education and experience considered in lieu of degree.
• Minimum of 5+ years of arbitrating or adjudicating and processing disputes of medical claims.
• Ability to perform comfortably in a fast-paced, deadline-orientated work environment.
• Familiar with Surprise Billing regulations, rules, and policies; and claims Arbitration procedures/practices preferred.
• Excellent organizational, interpersonal, written, and communication skills.
• Ability to work as a team member, as well as independently.
• Work across multiple systems, such as SharePoint, Salesforce, and Microsoft Office products.
• Legal writing experience, preferred.
• Medical coding experience, helpful.
EEO Statement
Active military service members, their spouses, and veteran candidates often embody the core competencies Maximus deems essential, and bring a resiliency and dependability that greatly enhances our workforce. We recognize your unique skills and experiences, and want to provide you with a career path that allows you to continue making a difference for our country. We're proud of our connections to organizations dedicated to serving veterans and their families. If you are transitioning from military to civilian life, have prior service, are a retired veteran or a member of the National Guard or Reserves, or a spouse of an active military service member, we have challenging and rewarding career opportunities available for you. A committed and diverse workforce is our most important resource. Maximus is an Affirmative Action/Equal Opportunity Employer. Maximus provides equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status or disabled status.
Pay Transparency
Maximus compensation is based on various factors including but not limited to job location, a candidate's education, training, experience, expected quality and quantity of work, required travel (if any), external market and internal value analysis including seniority and merit systems, as well as internal pay alignment. Annual salary is just one component of Maximus's total compensation package. Other rewards may include short- and long-term incentives as well as program-specific awards. Additionally, Maximus provides a variety of benefits to employees, including health insurance coverage, life and disability insurance, a retirement savings plan, paid holidays and paid time off. Compensation ranges may differ based on contract value but will be commensurate with job duties and relevant work experience. An applicant's salary history will not be used in determining compensation. Maximus will comply with regulatory minimum wage rates and exempt salary thresholds in all instances.
