Director – Appeals (Workers Compensation) - United States - 29420 - Maximus

General information

Job Posting Title

Director – Appeals (Workers Compensation)

Date

Tuesday, April 8, 2025

City

Remote

Country

United States

Working time

Full-time

Description & Requirements

Maximus is currently hiring for a Director – Appeals (Workers Compensation) to join our team. This is a remote opportunity and contingent upon award of contract. The Director will be responsible for managing a portfolio of programs.

***Please note that this position is contingent upon contract award***

Essential Duties and Responsibilities:
- Act as the primary contact for the state client
- Ensure program operations are in compliance with all applicable requirements of the contract, as well as State and federal regulations.
- Ensure goals and objectives are established by Project Manager that support the overall Project strategies.
- Oversee all project administrative operations including budget, financial controls, and human resources.
- Plan, develop and schedule priorities for achieving operational and performance goals.
- Review management, productivity, and financial reports and studies to ensure program objectives are met.
- Participate in internal audits, research studies, forecasts, and modeling exercises to support Project direction and guidance.
- Manage operational managers, to include performance appraisals, mentoring, and professional/development guidance.
- Demonstrate a high level of dedication and proactive leadership in meeting corporate goals and program objectives.
- 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 10+ years of relevant professional experience required.

- BA, BS, Registered Nurse (RN) with a valid nursing license or Masters or JD preferred.

- Experience in workers' compensation, utilization review, or related fields required.

- 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 internet 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

Maximus is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, age, national origin, disability, veteran status, genetic information and other legally protected characteristics.

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.