Manager - Eligibility - Maximus

Maximus is looking for an Eligibility Manager to support our FED No Surprises Act (NSA) project. This position is responsible for managing the overall eligibility review 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 Eligibility Manager will be responsible for the daily operations of the eligibility review staff. This role requires a deep understanding of the NSA, knowledge about healthcare service and items and strong critical thinking.

Essential Duties and Responsibilities:

- Stay updated on Enrollment and Eligibility performance standards, corporate, and project policies.

- Assist and inform staff about these policies and procedures.

- Provide guidance when handling escalated complaints and appeals.

- Identify and resolve employee issues, problems, and concerns.

- Address quality concerns with the Supervisory team regarding application and appeal reviews and corrections.

- Analyze weekly statistics, prepare daily and weekly reports.

- Monitor performance objectives for Enrollment and Eligibility Staff.

- Coach teams, set expectations, conduct performance evaluations, and support career development for assigned staff.

- Assess performance, provide appraisals, and implement corrective actions as needed.

- Evaluate training needs to ensure staff remains current with multiple programs.

- Keep leadership informed on quality, training, policies, procedures, staff issues, and departmental performance.

- Manage Eligibility Process: oversee the end-to-end eligibility review process, including intake, review, decision-making, and outreach with parties. Monitor performance objectives for eligibility staff.

- Review disputes: analyze disputes to determine the eligibility of the dispute and make decisions based on policy guidelines and regulations. Provide eligibility guidance for escalated disputes

- Compliance- ensure all eligibility decisions comply with relevant laws, regulations, and organizational policies. Address quality concerns with the eligibility 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 retarding the status and outcome of the eligibility review

- Team Leadership- manage and provide guidance to the eligibility teams, 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 eligibility review procedures and updates to policies and regulations. Ensure staff are fully informed and stay up-to-date on the NSA and related regulations

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.

- 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

Education:

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

- Law degree, paralegal ideal but not required

Remote Worker Requirements:

- Private and Secure workspace from home

- Access to Wi-Fi, LAN (wired connection/ethernet) or both at home

- Internet provider that offers enough speed for multiple users without latency or lag? (i.e., housemate also WFH, kids playing video games or streaming shows, etc.)

- Internet download speed of 25mbps single/50mbps shared and 5mbps (10 preferred) upload or higher required (you can test this by going to www.speedtest.net)

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.

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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.