This site uses cookies. To find out more, see our Cookies Policy

Supervisor - Appeals in Town of Pittsford, NY at Maximus, Inc.

Date Posted: 3/9/2018

Job Snapshot

Job Description

This role is primarily responsible for supervising team members to ensure members follow MAXIMUS policies and procedures. This role is also responsible for reviewing Administrative Law Judge (ALJ) decisions to determine whether a synopsis of perceived error(s) is appropriate and, if so, forwards the synopsis to the CMS COR as a monthly deliverable.   Reviews all Part C written inquiries and completes post-adjudication determination decision letters for disputes between providers and/or enrollees, and Medicare.  Assists in legal analysis and provides coaching and procedural instructions for variety of staff as requested.  Serves as be the Policy Subject Matter Expert (SME) for the Part C QIC Project.

  • Supervise team members ensuring members follow MAXIMUS policies and procedures
  • Assist members when necessary in coordination of appeal case processing and workload correction
  • Conduct periodic quality review of team members’ work product
  • Lead periodic team meetings to discuss team related issues and concerns
  • Perform reopening’s and all essential post-adjudication responsibilities
  • Perform quarterly bonus and annual reviews
  • Serve as the Policy Subject Matter Expert for the Part C QIC Project
  • Manage Administrative Law Judge (ALJ) activities for Part C including participating in hearings as necessary
  • Ensures coverage dispute reconsideration meet applicable quality standards; performs quality assurance reviews of certain reconsideration determinations
  • Reviews and Updates Part C specific Policy materials as appropriate and documents; communicates across the department where appropriate
  • Represents the Part C QIC on the QIC Change Control Committee
  • Key participant  in CMS Medical Forums and Project Audits
  • 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
The Ideal Candidate will Possess the Following Additional Education and Experience
  • Juris Doctor from an accredited law school; Must be a licensed attorney
  • RN preferred
  • Two to three years’ experience in law office or applicable experience
  • Ability to conduct comprehensive research in law and health policy
  • Excellent organizational, interpersonal, written, and verbal communication skills
  • Ability to successfully execute many complex tasks simultaneously
  • Ability to work as a team member, as well as independently
  • Demonstrate and promotes positive company relations
  • Proficiency in Microsoft Word and Excel and Internet research
EEO Statement 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.