• Health Care Attorney(Sacramento)

    Job Locations US-CA-Folsom
    Posted Date 1 month ago(12/10/2019 1:03 PM)
    Requisition ID
    # of Openings
    Job Schedule
    Regular Full-Time

    Since 1975, MAXIMUS has operated under its founding mission of Helping Government Serve the People, enabling citizens around the globe to successfully engage with their governments at all levels and across a variety of health and human services programs. MAXIMUS delivers innovative business process management and technology solutions that contribute to improved outcomes for citizens and higher levels of productivity, accuracy, accountability and efficiency of government-sponsored programs. With more than 30,000 employees worldwide, MAXIMUS is a proud partner to government agencies in the United States, Australia, Canada, Saudi Arabia, Singapore and the United Kingdom. For more information, visit

    Job Description Summary

    Essential Duties and Responsibilities

    This position will support clinical consulting service programs across multiple state clients including the California Department of Managed Health Care and California Department of Health Care Services. Programs cover multiple subject areas including billing disputes, fraud and abuse, pharmacy formulary review, development of average contract rate methodology and medical consulting. The position is targeted to candidates in the Sacramento, California region.

    The Consultant - Appeals will provide careful analysis of processes, techniques and procedures of cases in applying experience to ensure the appropriate practical determination is reached.

    Job Description Summary
    • Review cases to determine and summarize facts of each case assigned and assesses issues involved in the case
    • Research issues using federal law, federal regulations, relevant contract law and other sources as defined by the client contract
    • Review plan contracts and other relevant information and then make a decision as to whether an enrolled is entitled to benefits in cases involving contractual disputes
    • Communicate the determination in a clearly written format
    • Exercise independent judgment to ensure determination is accurate, well-supported and defensible and take appropriate action as required
    • Research issues using federal law, federal regulations, relevant contract law and other sources as defined by the client contract
    • Acquire all necessary information involving information and render final determination based on the information provided by the appellant
    • Perform other duties as may be assigned by Management

    Additional Duties and Requirements
    • Bachelor’s degree from an accredited college or university required
    • JD degree required
    • Minimum two (2) years’ experience in Health Care Appeals, Pharmacy Claims or other related fields required
    • Ability to successfully execute many complex tasks simultaneously
    • Ability to respond to the needs of outside contacts
    • Working knowledge and use of PC, claim adjudication, MS Word and Excel software, and appeals system software
    • Potential weekend & after hours coverage
    • Demonstrate teamwork and promote positive company relations
    • Excellent organizational, interpersonal, written and verbal communication skills

    Physical Requirements:
    • Ability to lift or transport objects up to 15 lbs.
    • Time spent sitting: 90%
    • Time spent standing: 10%
    • Ability to travel up to 10% of time
    • Work Environment: Office with Low Noise Level


    Essential Duties and Responsibilities:
    - Evaluate all data associated with appeals to determine compliance or exception to applicable regulations and policies, which may also require contacting the appellant to obtain additional information or clarify actions pertinent to the case.

    Minimum Requirements:
    - Bachelor's degree with 3-5 years of experience consulting within designated function.


    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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