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.

Please note that this position is contingent upon contract award

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 disability duration guidelines.
- Ability to work independently and as part of a team.
- Proficiency in using claims management software and other related tools.

Please note: For this position Maximus will provide equipment to use.

Home Office Requirements:

- Internet speed of 20mbps or higher required / 50 Mpbs for shared internet connectivity (you can test this by going to www.speedtest.net )
- Minimum 5mpbs upload speed
- Connectivity to the in ternet via either Wi-Fi or Category 5 or 6 ethernet patch cable to the home router
- Private work area and adequate power source
- Must currently and permanently reside in the Continental US

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.

Minimum Salary

$80,000.00

Maximum Salary

$105,000.00

As a leading strategic partner to governments across the globe, Maximus helps improve the delivery of public services amid complex technology, health, economic, environmental, and social challenges. With a deep understanding of program service delivery, acute insights that achieve operational excellence, and an extensive awareness of the needs of the people being served, our employees advance the critical missions of our partners. Maximus delivers innovative business process management, impactful consulting services, and technology solutions that provide improved outcomes for the public and higher levels of productivity and efficiency of government-sponsored programs.