Description:

Role Overview:
Legal Counsel Summary: Provides legal counsel, guidance, and recommendations on a broad range of legal, regulatory, and operational matters affecting the organization. Partners with business leaders to identify and mitigate legal risks, ensure compliance with applicable laws and regulations, and support strategic business objectives. Applies sound legal judgment and knowledge of the healthcare industry to deliver practical, business-focused solutions while supporting cross-functional initiatives, regulatory compliance efforts, and organizational growth.

Member Grievances and Appeals Focus: Reporting to the Associate Deputy General Counsel, this position will be primarily responsible for member grievances and appeals, working with internal stakeholders to respond to requests for information from governmental agencies, investigating and responding to appeals and complaints from members and representing the company in State Fair Hearings and related administrative proceedings.

Work Arrangement:

Hybrid- Associate must be in the Newtown Square, PA office at least three (3) days per week, including core days of Tuesdays and Wednesdays
For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Responsibilities:

Oversee the State Fair Hearing process including preparing witnesses and exhibits for hearings, drafting position statements, motions and related documents and representing health plans in state addressing appeals brought by members.
Represent company in administrative proceedings, including State Fair Hearings, agency actions and related proceedings involving disputes with members and/or providers related to benefits.
Research and/or interpret state and federal regulations, jurisdiction specific Medicare/Medicare contractual requirements, and Managed Care Organization policies and/or procedures applicable to cases pending before a judiciary and/or administrative agency.
Provide guidance, as necessary, to Associates and/or Paralegals of the Legal Department and outside counsel regarding case management, witness retention, and review of evidentiary submissions regarding cases pending before the judiciary and/or administrative agency.
Investigate complaints or grievances received from governmental agencies, advocacy groups and/or members and prepare responsive documents.
Identify potential legal risks and provide proactive advice and solutions to prevent issues before they arise.
Ensure compliance with applicable state/federal laws, contractual requirements and internal policies.
Operating with a high degree of integrity, in alignment with company mission and culture.

Education/Experience:

Law Degree (JD) from accredited law school and active Bar membership in Pennsylvania. Active DC license or interest in becoming licensed in DC strongly preferred.
3 or more years of litigation experience, including administrative hearings, arbitrations/trial and depositions.
Experience in health care industry preferred.

Other Skills:

The ability to synthesize dense medical terminology and legal statutes into clear, concise, and legally compliant decision letters.
Strong negotiation and dispute resolution skills. Capability to de-escalate complex disputes with angry members, providers, and state regulators.
Strong analytical, communication and problem-solving skills with the ability to provide clear and practical legal advice to non-lawyers.
Ability to present matters in Court and/or administrative agencies, interact with judges, court personnel, opposing counsel/advocacy groups.
Ability to work both independently and collaboratively, provide leadership, influence organization behavior and create alignment across organizational lines.
Excellent written and verbal communication skills, and the personal presence, credibility, and the professional demeanor necessary to interact with company management, regulatory bodies, and business units with persuasiveness and confidence.
Collaborative team player with an ability to effectively manage competing priorities.
Ready, willing and able to assist with new needs and comfortable with uncertainty and ambiguity.
Excellent judgment and the ability to prioritize and make difficult decisions quickly.
High integrity and confidentiality.