Manager - Appeals

Description & Requirements

Maximus is currently hiring for a Manager - Appeals to join our team.

This is a remote opportunity and contingent upon award of contract.

The Manager will be responsible for managing certain work streams and various types of cases.



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*Please note that this position is contingent upon contract award

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Essential Duties and Responsibilities:

- Manage assigned teams and staff.

- Develop, monitor, and use quality control procedures and audit criteria to ensure consistent application of contractual requirements and established policies and procedures.

- Frequent interaction with subordinate employees, customers, and/or functional peer group managers, normally involving matters between functional areas, other company divisions or units, or customers and the company.

- Provide guidance to subordinates within the latitude of established company policies.

- Recommend changes to policies and establish procedures that affect immediate organization(s).

- Perform other duties as assigned by management.

- Medical Necessity Reviews: Conduct reviews of clinical services to determine medical necessity based on established guidelines and criteria.
- Compliance: Ensure all reviews comply with state-specific workers' compensation regulations and standards.
- Case Management: Collaborate with healthcare providers, claims adjusters, and other stakeholders to manage cases effectively.
- Documentation: Maintain accurate and detailed records of all reviews and decisions made.
- Communication: Provide clear and concise communication to healthcare providers regarding review outcomes and recommendations.
- Education: Educate providers and staff on workers' compensation guidelines and utilization review processes.
- Quality Assurance: Participate in quality assurance activities to ensure the integrity and accuracy of the review process.

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.
- Familiarity with Appeals & Hearings is required.

Expertise within the Hearings & Appeals function is strongly preferred.

- BA, BS, Registered Nurse (RN) with a valid nursing license or Masters or JD.
- Experience in workers' compensation, utilization review, or related fields preferred.
- Strong analytical, communication, and organizational skills.

Proficiency in medical terminology and clinical guidelines.
- Relevant certifications such as CCM, COHN, or CRRN may be required.

- Knowledge of workers' compensation laws and regulations.

- Experience with New York State Workers' Compensation Guidelines (MTGs), New York State Workers' Compensation Board Drug Formulary (Formulary), New York State Workers' Compensation Fee Schedules (Medical, Dental, Durable Medical Equipment, Acupuncture and Physical & Occupational Therapy, Chiropractic, Behavioral Health and Podiatry).

- Familiarity with medical management practices and d...