Sr. Health Benefit Plan Consulting Attorney

Essential Duties

• Manage and support reviews of member and provider appeals, grievances, and complex claims issues, particularly in self-funded and ERISA-regulated plans
• Evaluate benefit exclusions, plan document terms, and medical necessity disputes to determine appropriate claim outcomes
• Cook with applicable vendors to ensure timely and accurate facilitation of independent clinical reviews
• Coordinate with applicable vendors to ensure timely and accurate facilitation of independent clinical reviews
• Review determination letters, appeal responses, and other member/provider-facing communications to ensure legal sufficiency and regulatory compliance
• Support internal audits, agency audits, corrective action plans, and external regulator or client requests, ensuring regulatory compliance
• Conduct legal research on applicable law and regulations; draft consulting memoranda; provide consultative advice, including analyses to our legal team for internal use
• Respond to client inquiries regarding agency rules, statutory requirements, and legal compliance
• Communicate with health plan administrators and other healthcare industry entities, including by phone, video conference, or in person; answer questions regarding the administration of compliant health plans; explain applicable law or health plan terms clearly and concisely
• Draft ERISA and ACA-compliant health plan documents, including MHPAEA required reports
• Aid in resolving disputes between various players in the healthcare industry
• Provide a thorough analysis of health plans and other related documents; provide a summary of findings to our legal team
• Other duties as assigned

Minimum Qualifications

• Juris doctor from an accredited law school and admittance to a state bar (active)
• 3-7 years of experience in the healthcare industry or in similar industries preferred (i.e., employment law, insurance law, disability law, workers’ compensation law)
• Superior legal writing, analytical, and proofreading skills, as well as strong attention to detail
• Outstanding organizational, interpersonal, and negotiation skills
• Ability to work collaboratively or independently as needed, and to work sensitively with confidential matters
• Ability to effectively communicate and interact with various positions throughout our organization as well as with clients
• Ability to successfully manage multiple projects, whether large or small, complex or simple, simultaneously
• Ability to participate effectively and confidently in client phone calls, including in occasional video conference calls
• Ability to anticipate issues and create and implement methods for optimizing results and minimizing risks
• Ability to develop a deep understanding of the business and our operational goals
• Comfortable working in a fast-paced environment
• High level of proficiency using Microsoft Word, Excel and Outlook
• Must be self-motivated and able to meet deadlines under pressure

Preferred Qualifications

• Excellent academic credentials
• Strong preference for experience working with health plans, third-party administrators, and/or health insurance carriers
• Familiarity with administrative rules published by relevant federal agencies, including HHS, the DOL, and the IRS
• Knowledge of CMS billing and payment rules and processes, or medical coding generally
• Confidence in public speaking
• Willingness to travel