Check out our latest 5BF (5 Bullet Fridays) where I boil down Medicaid/HHS industry into 5 bullets each week:
1. PHE extension to April
2. Medicaid concepts: Waivers
3. Recent HHS industry job listings
4. New CMS guidance on SDH funding
5. Fraud follies
A special treat for all your fraud lovers.
What is a Medicaid waiver?
A Medicaid waiver program is a special program that allows a state to vary from the standard Medicaid rules so that it can offer more targeted services to specific populations. Waiver programs are thus an alternative to the services in the State Medicaid Plan. While a state must provide the entire service array to anyone who meets the criteria of its Medicaid program, by using a waiver it can provide them only to certain groups (such as those with Traumatic Brain Injury, or those members who can get services inside their home and avoid a nursing home. Waivers must be approved by CMS, and have a capped funding amount.
What are the types of waivers available?
Each of the waiver types are commonly referred to by the part of the Social Security Act that governs them. See below for information on the most commonly used waivers:
- Section 1115 waivers- also known as demonstration waivers. These allow a state to test out a new financing model, cover a new population or a new service delivery model.
- Section 1915b waivers- also known as managed care waivers. These waivers allow a state to contract with health plans to deliver services to members.
- Section 1915c waivers- also known as home and community-based services (HCBS) waivers. These waivers allow states to offer services in the community to members that otherwise would need facility-level care.
The CMS list of state waivers
Want to learn more? Check out a related course
The Market Development Principal provides support to assigned health plan and/or specialty companies relative to Medicare/Medicaid/TRICARE product implementation, operations, contract compliance, and federal contract application submissions. The Market Development Principal provides strategic advice and guidance to functional team(s). Highly skilled with broad, advanced technical experience.
The Medicaid Behavioral Health Business Development Principal provides support to assigned business development team and/or specialty companies relative to Medicaid mental health and substance abuse business strategy and solutioning, implementation, operations, contract compliance, and federal contract application submissions. The Market Development Principal provides strategic advice and guidance to functional team(s). Highly skilled with broad, advanced technical and Medicaid behavioral experience.
The Medicaid Behavioral Health Business Development Principal serves as the primary resource and SME for business development. Ensures that RFP content and clinical model is meeting or exceeding corporate and state Medicaid requirements. Works with senior executives to develop and drive segment or enterprise-wide functional strategies. Advises one or more areas, programs or functions and provides recommendations to senior executives on matters of significance, and as an advanced subject matter expert competent to work at very high levels in multiple knowledge and functional areas across the enterprise.
- Bachelors Degree
- Experience in fully integrated physical and behavioral clinical models
- 10 years working experience in leading mental health and substance abuse Medicaid strategy for complex populations
- 10 years working experience in leading Medicaid strategy for complex populations
- 10 or more years of program design, execution and measurement in the Medicaid population
- 5 years of project/people leadership
- Experience as subject matter expert in Medicaid RFP process
- Strategic thinking and planning capabilities
- Organized and detail-oriented
- Excellent presentation and communication skills, both internal and external audiences
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences
- Able to effectively work in matrix organization and influence senior leadership level key stakeholders
- Graduate Degree
- Experience evaluating competitor capabilities, determining where there are gaps and making recommendations to close them
Scheduled Weekly Hours
Clipped from: https://www.glassdoor.com/job-listing/principal-clinical-business-development-medicaid-humana-JV_KO0,48_KE49,55.htm?jl=3747214614&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic
Medicaid Care Coordinator (REMOTE)
Duration: 6+ month contract (likely to extend)
Location: Chicago, IL 60601
Pay Rate: $24.45/hr
Overview: The CRS Group is currently looking for a Medicaid Care Coordinator (REMOTE) for one of our clients in the Chicagoland area. The CRS Group is a nationwide Staffing Firm who works primarily with Fortune 500 and Fortune 1000 corporations.
Duties and Responsibilities:
- This position is responsible for monitoring Medicaid/Medicare and related regulations and policy changes impacting clinical operations
- Participating in audits
- Supporting tracking and submission of Medicaid State Contract(s) related deliverables, including fulfillment of internal and contractual reporting requirements
- Working with other areas of the organization on the development, testing and implementation of organization, process and system changes to ensure the requirements of the Medicaid program are met
- Assisting MMP in coordination of the contract with the State/CMS enterprise-wide.
- Bachelor Degree in Business OR 2 years’ experience with health insurance.
- 1 year of experience with health insurance benefits and/or operations.
- Knowledge of Medicaid and Medicare product(s).
- Verbal and written communication skills.
- Experience presenting trends and findings in meetings with management.
- Experience organizing multiple tasks and responsibilities.
- Experience analyzing data reports.
- Experience developing and running queries in a database.
- PC proficiency to include Microsoft Word, Excel, PowerPoint, and Outlook
- Knowledge of health benefits.
- Knowledge of Health Plan Clinical Operations.
Working remotely within the United States is acceptable for this position.
What you will do:
Oversees one or more software products end-to-end and assists in the direction of particular project-level activity and associated team personnel.
Works under general supervision.
Maintains relationship with client, project scope can increase in complexity and size.
Manages client relationships at the client customer work site.
Provides project management for prime or sub-contractor, fixed price, or time and materials projects.
Provides project management on projects with a team size that is up to 100 employees concurrently.
Provides project management on projects with annual total contract value of up to $50M and complexity (hours) of up to 300,000 hours.
Provides end-to-end responsibility for one or more products, sub-systems or level responsibilities.
Develops detailed, resource loaded project schedule with the required metrics.
Confers with project personnel to provide technical advice and to resolve problems.
Manages project risk by working with project schedulers to track project schedules, deliverables, and milestones; monitors costs and schedules using EVM and other tools.
Oversees and develops a feasible plan for one or more software products that achieves the goals and objectives of the project and aligns with the organization’s overall business strategy.
Assists in developing a feasible plan that achieves the goals and objectives of the project and aligns with the organization’s overall business strategy.
Determines project scope and recommending and assigning resources as available.
Determines estimated time and financial commitment of project, and in monitoring progress.
Implements, maintains, and reports Earned Value (EV) metrics into project plans.
Implements, maintains, and reports CNSI project delivery metrics into project plans.
Assists in monitoring and developing a project budget and tracking actual spend compared to the planned budget, escalating to senior leadership as needed.
Partners with customers and analyzes issues and problems from the customer perspective.
Provides customer-facing presentations on quality.
Communicates and provides status to define, schedule, and accurately estimate the task duration for project schedule.
Possesses unwavering commitment to customer service and operational excellence.
Keeps abreast of new technology and market developments.
Adheres to CNSI CMMI standards and processes.
Manages internal customer relationships for long-term corporate success
Requests and gives both negative and positive feedback.
Recruits highly skilled, motivated leaders and individual contributors and recommends potential new hire resources to meet client commitments in alignment with program delivery.
Familiarity with medical bill and provider enrollment forms.
Identify reoccurring problems and provide feedback to management to affect change.
Familiarity with payment adjustments, claim disputes, prior authorization, claims processing,
Manage sensitive data in accordance with HIPAA and Medicaid regulations.
We are proud to be a partner to the public sector, a trail blazer in health IT and a passionate advocate for better health, better care and lower costs for millions of Americans. Innovation is core to our DNA and through our iCare program we invest in the well-being of our employees and the communities in which we live and work. You will be offered a solid compensation package which includes:
- Annual and Other Paid Leave
- Medical/Dental Insurance
- Flexible Spending Account (FSA) Plan
- Disability Insurance (Short & Long Term)
- Life Insurance
- 401(k) Retirement Savings Plan
- Employee Assistance Program
- College Savings Plan
- Tuition & Training Assistance
- Paid Holidays
- Employee Referral Program
CNSI maintains a policy supporting equal employment opportunity. Employment decisions at CNSI are made without regard for race, color, religion, sex, national origin, age, disability, sexual orientation, gender identity, marital status, genetic status, family responsibilities, protected veteran status or any other status protected by applicable Federal, state, or local law. We are proud of our diversity and encourage all qualified applicants to apply.
- 15 year(s): Experience in project planning, delivery, and management
- 2 year(s): Experience in provider management, claims processing, prior authorization, and/or other related projects.
- Demonstrates leadership skills and ability to work effectively with different teams and contributors both directly and in a matrix environment.
- Domain knowledge of Medicare, Medicaid, or healthcare verticals.
- Ability to manage people, projects, and processes.
- Strong understanding of project management skills and ability to create and manage project plans.
- Expertise in Microsoft Schedule
- Understanding of SharePoint applications, WebEx, Skype, etc.
- Familiarity with medical bill forms, ICD-9/10CM coding, CPT coding, bill forms, and other medical coding schemes.
- Ability to meet and enforce deadlines, to conduct research into technology issues and products, and to take initiative in the development and completion of projects.
- Knowledge of Microsoft Word, Excel, and Visio with a working knowledge of the rest of the Microsoft Office suite of applications.
- Strong knowledge of Microsoft Project EV metrics.
- Strong problem-solving, analytical, and evaluative skills.
- Strong communication skills (verbal, written, facilitation) with strong presentation and facilitation skills.
- General knowledge of medical terminology
- Bachelors or better
- Masters or better
Licenses & Certifications
- Prof in Project Mgmt Cert
- Team Player: Works well as a member of a group
- Leader: Inspires teammates to follow them
- Functional Expert: Considered a thought leader on a subject
- Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35©
Clipped from: https://www.glassdoor.com/job-listing/project-manager-medicare-medicaid-or-healthcare-verticals-remote-position-cnsi-JV_IC1155583_KO0,73_KE74,78.htm?jl=3691352252&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic
Req ID: 71883BR Job Description Program Overview Help us elevate our patient care to a whole new level! Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our Dual Eligible Special Needs Plan (DSNP) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges.
With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members’ health care and social determinant needs. Join us in this exciting opportunity as we grow and expand DSNP to change lives in new markets across the country. Fundamental Components included but are not limited to: Position Summary The Health Survey Specialist plays a critical role within the DSNP team.
The Health Survey Specialist outreaches DSNP members via phone to introduce the DSNP services and complete the Health Risk Assessment (HRA). The HRA is the first step in creating the member’s Individualized Care Plan and sets the foundation for follow up care management by assessing a member’s medical, functional, cognitive, psychosocial, and mental health needs. Fundamental Components + Uses motivational interviewing and other consultative techniques to gather comprehensive information about a member’s medical, functional, cognitive, psychosocial, and mental health needs + Accountable to the highest level of compliance integrity + Champions for the member by connecting members with urgent needs to the appropriate Aetna team, including DSNP’s interdisciplinary care team and customer service + Initiates engagement with assigned members to introduce the program and drive active participation in completion of their Health Risk Assessment + Builds a trusting relationship with the member by engaging the member in meaningful and relevant conversation, prior to and during assessment + Effectively supports members during enrollment calls, appropriately managing difficult or emotional member situations, responding promptly to member needs, and demonstrating empathy and a sense of urgency when appropriate + Conducts triage, connecting members with appropriate care team personnel including care managers and customer service when needed + Accurately and consistently documents each call in the member’s electronic record, thoroughly completing required actions with a high level of detail to ensure we meet our compliance requirements + Protects the confidentiality of member information and adheres to company policies regarding privacy/ HIPAA + Ability to be agile, manage multiple priorities, and adapt to change with enthusiasm + Determined to build strong relationships with peers and our DSNP members + Demonstrates an outgoing, enthusiastic, and caring presence over the telephone Qualifications Requirements and Preferences: + At least 3 years of experience in health care, customer service, telemarketing and/or sale + Familiarity with basic medical terminology, health care, and the concepts of care management + Medicare/Medicaid/DSNP experience preferred + Experience with computers, including knowledge of Microsoft Word, Outlook, and Excel required + Strong organizational skills, including effective verbal and written communications skills required + Data entry and documentation within member records is strongly preferred + Flexibility with work schedule to meet business needs + Bilingual desired Education and Certification Requirements + High School diploma or G.E.D.
required + Associates/Bachelor’s degree preferred Benefit Eligibility Benefit eligibility may vary by position. Job Function: Customer ServiceAetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.
Clipped from: https://www.ziprecruiter.com/c/Aetna/Job/Health-Survey-Specialist-Service-Advocate-Work-at-Home/-in-Louisville,KY?jid=803c0c97550317ef&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic