Title: Medicaid Fair Hearing Officer
Location: Richmond, VA 23219
Pay Rate: $50.00/Hour on W2 without benefits
Duration: 6+ months
Shift Timing (Day/ Evening/ Night): Day
Job Description:
- Go though appeal requests and case documents to prepare for and conduct hearings. Write clear decisions based on facts and legal rules, following fair hearing standards and deadlines.
Use legal knowledge:
- Apply laws, rules, and procedures to make fair and accurate decisions. Do legal research, analyze evidence, and manage your cases independently to meet timelines.
Ensure fairness and respect:
- Provide respectful and professional service to everyone. Make sure each person gets a fair hearing and help maintain a positive team environment.
Reporting:
- This role reports to the Eligibility Cases Manager.
Required knowledge, skills, and abilities (KSAs):
- Experience in a fast-paced, deadline-driven environment
- Experience independently managing a caseload to meet established time frames
- Experience with internal and external stakeholders
- Knowledge of administrative law and/or appeals procedures
- Considerable experience applying rules to facts to reach logical, legally supportable conclusions
- Considerable experience interpreting, applying, and analyzing federal and state complex laws, regulations, policies, or case law
- Considerable experience in legal analysis and legal writing
- Considerable knowledge of legal research methodologies, including computerized legal research
- Considerable experience with technology, including MS Office
- Admission to the Virginia State Bar in good standing, or eligible for admission to the Virginia State Bar within six months from the start date in the position.
Additional Considerations:
- Experience drafting appeal decisions.
- What work actions and/or decisions are made without prior approval? To what extent is the incumbent required to seek advice and guidance from the supervisor?
- Independently manage issues and risks proactively and exercise strong business judgment in escalating matters to the Eligibility Cases Manager.
- Independently research state and federal laws, regulations, and policy.
Role & Responsibilities:
- Conduct thorough hearing preparation and hearings for all Medicaid appeal cases assigned to inventory.
- Follow all rules and procedures set by the Appeals Division
- Use the Appeals Information Management System (AIMS) effectively to track cases, complete tasks, add notes, and manage appeal activities
- Keep case records accurate and up to date by regularly updating files and logging actions in AIMS
- Handle your own set of cases and complete hearing prep work on time
- Research legal issues thoroughly and stay informed about current laws, policies, and regulations that affect appeal decisions
- Lead client eligibility appeal hearings using proper legal procedures, ensuring fairness and due process
- Share case-related data and performance metrics with the Eligibility Cases Manager when requested.
Draft and issue legally supportable state fair hearing decisions in accordance with all deadlines:
- Follow all established procedures of the Appeals Division
- Use the Appeals Information Management System (AIMS) confidently to:
- Attach hearing recordings
- Upload final decisions and exhibit packets
- Handle decision submissions, including resubmission requests
- Ensure decisions are released on time so they can be mailed by the print vendor before the deadline
- Apply laws, rules, regulations, and policies to make fair and well-reasoned written decisions based on facts and legal conclusions
- Submit decisions to the Quality Assurance Team within required timeframes, focusing on meeting federal deadlines
- Make sure all decisions are released in AIMS before their due dates
- Share performance data and case metrics with the Eligibility Cases Manager when requested
Collaborate with Appeals Division team members:
- Build productive working relationships with peers and work collaboratively to manage the flow of appeals
- Assist with increased workload volume across teams, as requested
- Complete assigned tasks and projects in a timely manner
- Communicate effectively both orally and in writing with various staff members as it relates to assigned tasks and projects
- Assist with training, as requested, to ensure continuity of operations
- Immediately escalate issues between peers to management to ensure that an effective resolution can be reached in a timely manner
Special Assignments:
- Special assignments are made at the request of the Eligibility Cases Manager, General Operations Manager, and Division Director.
- Satisfactory completion of assignments within timeframes established by the Eligibility Cases Manager, General Operations Manager, and Division Director.
Departmental Objectives:
- The Department of Medical Assistance Services is committed to providing the highest quality customer service in all aspects of its mission and to all its external customers and internal employees.
- The Department's goal is to provide the highest quality customer service through personal accountability and professional commitment; practicing teamwork and supporting fellow co-workers; treating others with dignity, integrity and professionalism; setting positive examples; responding to customers and colleagues in a timely, efficient, responsible, pleasant and courteous manner; and, thoroughly assessing the impact of every action or non- action we take on our customers and internal processes prior to program implementation or changes in process.
Department Medical Assistance Services - Equity, Diversity and Inclusion:
- The Department's goal is to provide a workplace that fosters and sustains a highly-qualified, diverse workforce drawn from all segments of society. DMAS cultivates a culture that encourages inclusion, collaboration, flexibility, and fairness to empower individuals to contribute to their optimum potential and feel valued.
Follows the HIPAA Policy and Procedures
- This position is occasionally responsible for the privacy and security of Protected Health Information (PHI) and/or maintaining reasonable and appropriate safeguards to: ensure the confidentiality, integrity and appropriate release of all PHI; protect against reasonable anticipated threats or hazards to PHI; protect against anticipated unauthorized uses or disclosures of PHI; protect PHI transmitted or maintained in any form or medium; and ensure proper use of secure e-mail at all times so that there is no inappropriate releases or disclosures of PHI. Any privacy or security violations must be reported to the Office of Compliance and Security.
Continuity of Operations Plan:
- Generally may be required to assist the Agency in situations where the Continuity of Operations Plan (COOP) has been activated.
Emergency Preparedness Responsibilities:
- May be required to assist the agency or state government generally in the event of an emergency declaration by the Governor
Certification and Training:
- Participation in and completion of all training and certification required by the state and management.
Performance Factors:
- These general performance traits help assess an employee's overall effectiveness and specific job responsibilities. They should be reviewed with the employee at the start of the performance cycle and used to guide performance ratings and feedback.
Interpersonal Relations:
- How well the employee builds positive working relationships with supervisors, colleagues, clients, and customers. This includes earning trust and delivering excellent customer service.
Safety:
- How consistently the employee follows safety guidelines and takes action to correct unsafe practices in the workplace.
Communication Skills:
- The employee's ability to clearly and effectively share ideas both verbally and in writing, as needed to meet job expectations.
Planning, Analysis, and Decision Making:
- How well the employee gathers and evaluates information, anticipates problems, and makes sound decisions. This includes analyzing issues, weighing outcomes, and adapting to changes while taking initiative in a fast-paced setting.
Attendance and Punctuality:
- The degree to which the employee's presence and timeliness support consistent and reliable job performance.
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