Manager - Appeals - Maximus

Maximus is looking for a Payment Determinations Manager to support our FED No Surprises Act (NSA) project. This position is responsible for managing the payment determination decision process for disputes in the Independent Dispute Resolution process between healthcare providers and insurance companies. This position must be able to use a range of measurements to forecast, monitor, analyze, plan, and manage resources to achieve contractual service level agreements, while maintaining a high level of customer service. The Payment Determinations Manager will be responsible for the daily operations of the payment determinations staff. This role requires a deep understanding of the NSA, knowledge about healthcare service and items and strong critical thinking.

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.

- Manage Payment Determination Decision Process: oversee the payment determination decision process. Monitor performance objectives for eligibility staff.

- Review Disputes and Payment Determination Decisions: review disputes for eligibility as well as payment determinations and make decisions based on policy guidelines and regulations. Provide payment determination guidance for escalated disputes.

- Compliance- ensure all payment determination decisions comply with relevant laws, regulations, and organizational policies. Address quality concerns with the payment determination teams.

- Documentation- maintain accurate and detailed records of all disputes, decisions, and communications.

- Stakeholder Communication- Act as the primary point of contact for parties, providing clear and concise information regarding the status and outcome of the payment determination review.

- Team Leadership- manage and provide guidance to the payment determinations team, ensuring high standards of performance and professional development. Coach teams, set expectations, conduct performance evaluations, and support career development for assigned staff. Identify and resolve employee issues, problems, and concerns.

- Continuous Improvement- identify areas for process improvement and implement changes to enhance the efficiency and effectiveness of the eligibility process.

- Reporting- prepare regular reports on eligibility outcomes, trends, and performance metrics for management.

- Training- conduct training sessions for staff and stakeholders on payment determination procedures and updates to policies and regulations. Ensure staff are fully informed and stay up-to-date on the NSA and related regulations.

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.

Education:

- Law degree highly preferred

- Bachelor's degree in relevant field of study and 5+ years of relevant professional experience required

Experience:

- At least 2 years in a supervisory or managerial position

- Experience in healthcare law, arbitration, mediation, dispute resolution or claims and appeals adjudication in healthcare.

- Strong analytical and critical thinking skills.

- Excellent written and verbal communication abilities.

- Ability to handle sensitive information with integrity and confidentiality.

Knowledge

- Strong understanding of relevant laws, regulations, and policies related to the NSA working knowledge of Medical and Insurance Terminology.

Skills

- Excellent analytical and decision-making skills

- Strong written and verbal communication skills

- Proficiency in Microsoft Office Suite and experience with database management

- Ability to manage multiple priorities and work under pressure

- Strong leadership and team management skills

Remote Position Requirements:

- Noise free Private and Secure workspace from home

- Wired internet connection with minimum download speed of 25 mbps and minimum upload speed of 10mbps (No Hotspots or Wifi)

- Wired USB headset

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.