Appeal Officer / Health Care Attorney

Description:

Requirements:
An IT Service Management Company is looking for a Consultant Appeals. This is a full-time, fully remote position.

Essential Duties and Responsibilities:

• Subject matter expert for the most complex Appeals and Hearings cases.
• Evaluate data associated with complex customer issues to determine compliance or to make exceptions to applicable regulations and policies; may require contacting the customer to obtain additional information or clarify actions pertinent to the case.
• Research laws and regulations and apply rules to case-specific situations.
• Provide complaint resolution to customers verbally or in writing, utilizing discretion.
• May attend hearings and/or management meetings to discuss cases.
• Review cases to identify and summarize key facts of each case and assess medical and legal issues involved in the case
• Research issues using California law, California regulations, current peer-reviewed medical literature, clinical guidelines, and other sources as defined by the client contract
• Determine the adequacy of medical records and request relevant medical records as needed
• Communicate the determination in a succinct written format
• Exercise independent judgment to ensure determination is accurate, well-supported, and defensible.
• Familiarity with medical terminology and/or medical record review required.
• Familiarity with California health care law/Knox Keene Act and managed health care preferred.
• Familiarity with California health care law/Knox Keene Act and managed health care preferred.

• Hardwired internet (ethernet) connection.
• Internet download speed of 25mbps single upload or higher required (you can test this by going to www.speedtst.net).
• Private work area and adequate power source.
• Video calls may be requested on occasion. Proper background and attire is required.

Minimum Requirements:

• Juris Doctorate Required.
• Familiarity with medical terminology and/or medical record review required.

Minimum Requirements:
Bachelor's degree in relevant field of study and 3+ years of relevant professional experience required, or equivalent combination of education and experience.

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