• Sr Consultant - Appeals

    Job Locations US-NY-Pittsford
    Posted Date 7 days ago(5/14/2018 10:05 AM)
    Requisition ID
    # of Openings
    Job Function
    Job Schedule
    Regular Full-Time
  • Overview


    The Sr. Consultant - Appeals will collaborate with medical experts and project staff in order to develop an independent medical/legal review for various state agencies as well as a few federal programs. Responsible for tracking and managing cases throughout the entire lifecycle. Responsible for developing completing high quality reviews that are well written and evidenced/regulation based. Serves as legal SME.



    • Oversees the appeals process for many state projects and a few federal projects
    • Analyze and render coverage dispute reconsiderations for state and federal projects
    • Ensures coverage dispute reconsideration meet applicable quality standards; performs quality assurance reviews
    • Collaborates with nurses and clinical/medical experts in order to produce a high quality review
    • Research, analyze and apply state and federal regulations
    • Stays current with regulations that apply to all assigned projects
    • Reviews, edits and critiques reviews
    • Documents and updates workflows and best practices
    • Facilitates/leads conference calls with customers
    • Participates in hearings to explain and defend decisions
    • Ensures contractual requirements are met
    • 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
    • Two to three years’ experience in law office or applicable experience
    • Proven experience in working in fast paced environment
    • 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
    • Experience with communicating directly with government agencies desired
    • Ability to work as a team member, as well as independently; experience working in a matrix reporting structure
    • Demonstrate and promotes positive company relations
    • Proficiency in Microsoft Word, Excel, Visio and Internet research
    • Litigation experience preferred
    • Legal writing experience preferred
    • Advanced health-related degree is desirable
    • Minimum of five (5) years’ experience interpreting healthcare regulations is desired

    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.


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