Description & Requirements

Maximus is currently hiring a Team Leader - Medical to support the Independent Medical Review (IMR) and Independent Billing Review (IBR) programs. In this role, you will oversee complex case management, ensure compliance with contract regulations, and serve as a subject matter expert in IMR and IBR processes. You will collaborate with Claims Administrators, the CA Division of Workers' Compensation (DWC), and internal teams to manage appeals, eligibility determinations, and procedural enhancements. This position requires strong analytical skills, excellent communication, and leadership abilities to drive operational excellence.

What You Will Receive:

• Work/Life Balance Support - Flexible work arrangements tailored to your needs!
• Competitive Compensation - Performance-based bonuses included!
• ️ Comprehensive Insurance Coverage - Medical, Dental, Vision, Prescription, HSA, Life Insurance, and discounts on Auto, Home, Renter’s, and Pet Insurance.
• Future Planning - 401K Retirement Savings plan with Company Matching.
• ️ Paid Time Off Package - PTO, Holidays, Extended Sick Leave, and Short/Long-Term Disability coverage.
• Holistic Wellness Support - Employee Assistance Program (EAP) for physical, emotional, and financial well-being.
• Recognition Platform - Celebrate outstanding employee contributions.
• Diversity, Equity, and Inclusion Initiatives - A workplace committed to fostering diversity and inclusion.
• Tuition Reimbursement - Invest in your ongoing education and professional growth.
• Employee Perks and Discounts - Exclusive benefits and discounts for employees.
• Maximus Wellness Program & Resources - Access a variety of wellness programs designed for your needs.
• Professional Development Opportunities - Participate in training programs, workshops, and conferences.

If you are an organized, detail-oriented professional with expertise in medical review and billing processes, we encourage you to apply and make an impact at Maximus!

Essential Duties and Responsibilities:
- Monitor the performance of, manage workloads of and perform case assignment for a team of Coordinators and assist with training and staff hiring.
- Develop and maintain processes and procedures at the direction of the director, liaison with Project Directors regarding procedural issues, and communicate with the CA Division of Workers' Compensation (DWC) regarding policy and eligibility issues.
- Manage complex case files from the date received to date closed for Independent Billing Review (IBR) and determine eligibility of CA IBR appeals.
- Respond to requests from Billing for additional information from Claims Administrators as needed.
- Manage complex case files from date received to date closed.
- Determine eligibility of appeals and submit potentially ineligible cases to the CA DWC for final eligibility determination.
- Request additional information from Claims Administrators.
- Draft correspondence regarding eligibility and assignment.
- Manage the workload of all Coordinators to ensure timeliness of IBR reviews.
- Collaborate with the client to address policy issues that arise in the content of review.
- Ensure that process is being completed timely according to contract regulations.
- Work with Systems Development staff regarding Entellitrak updates to enhance IBR process.
- Perform other duties as assigned by management.

- Ability to clearly communicate data and results in written report form.
- Excellent organizational, interpersonal, written, and verbal communication skills..

- Act as a subject matter expert in the areas of Preliminary Review, IBR requirements and eligibility.

- Handle and oversee IBR Help desk emails.

- Proficient excellent analytical, critical thinking and problem-solving skills.

Minimum Requirements

- High School diploma or equivalent or Associate degree with 1.5 - 4 years of experience.
- Additional training or education in area of specialization.
- Works on a variety of assignments requiring considerable judgement and initiative.
- As a skilled and experienced specialist, completes tasks in resourceful and effective ways.
- Able to draft or modify training materials and procedural documentation accurately.
- Skilled in handling challenging communications with external contacts for escalated matters.
- Act independently to determine methods and procedures on new assignments.
- Serves as facilitator and team leader, allocating work and providing guidance and training to others in field of specialization.
- Perform quality assurance on work of others in team.

-Experience in medical claims billing, claims processing or coding
-Strong proficiently with MS Office Suite (Word, Excel, Power Point)

Home Office Requirements:

• Candidates must have their own cell phone
• Maximus provides company-issued computer equipment
• Reliable high-speed internet service
  • Minimum 20 Mpbs download speeds/50 Mpbs for shared internet connectivity
  • Minimum 5 Mpbs upload speeds

#NYMC #NYMCCSR #LI-Remote

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

$32.00

Maximum Salary

$32.00

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.