Author: MM_ADMIN

 
 

Location: Company:

 
 

Description
Humana Healthy Horizons in Louisiana is seeking a Manager, Utilization Management (Behavioral Health) who will utilize clinical skills to support the coordination, documentation, and communication of behavioral health services and/or benefit administration determinations. The Manager, Utilization Management Behavioral Health applies a Person-Centered approach, works within specific guidelines and procedures; applies advanced technical knowledge and clinical criteria to solve moderately complex problems; receives assignments in the form of team and/or department goals and objectives and determines approach, resources, schedules and monitors success of appropriate team or department S.M.A.R.T goals.
Responsibilities
Essential Functions and Responsibilities
– Supervise utilization management personnel and oversee all utilization management functions, including inpatient admissions, concurrent review, prior authorization and referrals to care management.
– Oversee, monitor, orient and train staff in the use of standard utilization management criteria including ASAM.
– Lead development of utilization management policies and procedures to ensure compliance with state and federal requirements and incorporate industry best practices.
– Collaborate with internal departments, providers, and community partners to support the delivery of high-quality utilization management services, including introducing innovative approaches to utilization management.
– Monitor and maintain staffing levels to meet care and service quality objectives.
– Conduct timely evaluations of direct reports and provide regular opportunities for professional development.
– Influence and assist corporate leadership in strategic planning to improve effectiveness of behavioral health utilization management programs.
– Collect and analyze performance reports on utilization management functions to monitor adherence with benchmarks, identify opportunities for process improvement, and develop recommendations to leadership.
– Conducts briefings and area meetings; maintains frequent contact with other managers across the department and the company.
Required Qualifications
– Must reside in the state of Louisiana.
– Licensed Mental Health Practitioner (LMHP) who is licensed to practice independently in Louisiana and is in compliance with the requirements of one of the following regulated areas: Medical Psychologists, Licensed Psychologists, Licensed Clinical Social Workers (LCSWs), Licensed Professional Counselors (LPCs), Licensed Marriage and Family Therapists (LMFTs), Licensed Addiction Counselors (LACs) or Advanced Practice Registered Nurses (APRN) with specialization in adult psychiatric and mental health.
– Two (2) or more years of clinical experience working with the behavioral health populations preferably in an acute care, skilled or rehabilitation clinical setting.
– Previous experience in utilization management.
– Two (2) years of leadership experience.
– Knowledge of ASAM, Interqual and/or Milliman (MCG) criteria.
– Comprehensive knowledge of Microsoft Office applications including Word, Excel, and Outlook.
– Ability to work independently under general instructions and with a team.
– Must have the ability to provide a high speed DSL or cable modem for a home office.
– A minimum standard speed for optimal performance of 25×10 (25mpbs download x 10mpbs upload) is required.
– Satellite and Wireless Internet service is NOT allowed for this role.
– A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
– This role is part of Humana’s Driver safety program and therefore requires an individual to have a valid state driver’s license and proof of personal vehicle liability insurance with at least 100,000/300,000/100,000 limits.
– Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.
Preferred Qualifications
– Certified Case Manager (CCM) or willingness to obtain within 2 years of employment.
– Experience serving Medicaid, TANF, and/or CHIP populations.
Additional Information
– Workstyle: Remote.
– Travel: 25% in-state travel.
– Direct Reports: up to 12 Associates.
– Section 1121 of the Louisiana Code of Governmental Ethics states that current or former agency heads or elected officials, board or commission members or public employees of the Louisiana Health Department (LDH) who work directly with LDH’s Medicaid Division cannot be considered for this opportunity. A separation of two (2) or more years from LDH is required for consideration. For more information please visit: Louisiana Board of Ethics (la.gov) (https://ethics.la.gov/boardprocedures.aspx?type=advisory%20opinion)
Interview Format
As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.
If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.
If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Scheduled Weekly Hours
40

 
 

 
 

Clipped from: https://www.adzuna.com/details/3450972865?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Director Business Development – Medicaid
 

• SUNRISE Drive, Reston, VA 20192, USA
  
• Full-time
  

Company Description

At hCentive we’re changing the way benefits are managed. Our software helps to simplify the complex world of shopping, enrolling, and managing health, ancillary, and voluntary benefits. As the industry leader in the benefits management space, we proudly support local and state government agencies, insurance brokers, employers and their employees. We’ve proven time and time again that we deliver cutting-edge software solutions that our clients value for business growth and financial success.

Job Description

Position Summary

This critical opportunity is a hybrid position that will combine your product management expertise with your business development acumen. We are seeking an individual that has experience managing product management teams and implementing strategic project management methodologies like Pragmatic Marketing Framework or Optimal Product Process as well as Business Development success selling to State Government HHS, Local Government or related organizations and be intimately familiar with Federal Eligibilities.

The selected individual will embrace the values of integrity, transparency, professionalism and mutual respect and be customer/client focused with superb presentation skills.

Required Skills and Experience

• 10+ years Product Management experience building SaaS products.
  
• 8+ years of documented Business Development success.
  
• Medicare and Human Services policy and domain experience.
  
• Ability and experience in driving complex government sales and deep knowledge of government procurement practices.
  
• Demonstrated success in establishing strategic partnerships with complementary product organizations and systems integrators.
  
• Experience with Health Care Products and Services
  
• Experience building B2B/B2C SAAS products.
  
• Solid experience in proposal preparation.
  
• Strong project management skills with attention to detail and situational fluency and ability to influence and motivate others, and perseverance to handle challenging business situations ls of management.
  
• Excellent written and oral communication skills at multiple levels within an organization.
  

Desired Skills and Experience

• Experience with Product Market Analysis.
  
• Experience writing business plans for new product development.
  
• Understanding of and experience in UX, including strategy, interaction design, and user-centered design.
  
• Business Acumen
  
• Strategic Thinking
  
• Problem Solving/Analysis
  
• Time Management
  

EDUCATION:

 

Bachelor’s Degree in Engineering, Marketing, Business, or related field is required, Master’s Degree preferred

Qualifications

Required Skills and Experience

• 10+ years Product Management experience building SaaS products.
  
• 8+ years of documented Business Development success.
  
• Medicare and Human Services policy and domain experience.
  
• Ability and experience in driving complex government sales and deep knowledge of government procurement practices.
  
• Demonstrated success in establishing strategic partnerships with complementary product organizations and systems integrators.
  
• Experience with Health Care Products and Services
  
• Experience building B2B/B2C SAAS products.
  
• Solid experience in proposal preparation.
  
• Strong project management skills with attention to detail and situational fluency and ability to influence and motivate others, and perseverance to handle challenging business situations ls of management.
  
• Excellent written and oral communication skills at multiple levels within an organization.
  

Desired Skills and Experience

• Experience with Product Market Analysis.
  
• Experience writing business plans for new product development.
  
• Understanding of and experience in UX, including strategy, interaction design, and user-centered design.
  
• Business Acumen
  
• Strategic Thinking
  
• Problem Solving/Analysis
  
• Time Management
  

EDUCATION:

 

Bachelor’s Degree in Engineering, Marketing, Business, or related field is required, Master’s Degree preferred

Additional Information

hCentive is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

All your information will be kept confidential according to EEO guidelines.

Director Business Development – Medicaid

Clipped from: https://www.learn4good.com/jobs/reston/virginia/business/1449272422/e/

 
 

Job Description

Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:

• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women

• Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR

• Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.

• Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.

Improving Members’ experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.

Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.

Skills / Requirements

JOB SUMMARY: The Risk Adjustment Analyst will utilize and evaluate claims, authorization, member and provider data to assist the Director of Quality Validation to develop, track and monitor healthcare quality metrics, cost and make recommendations to support business decisions.  The Risk Adjustment Analyst will exhibit familiarity with using data from various relational databases.   The Risk Adjustment Analyst generates departmental performance reports, validates results and makes recommendation on how to interpret information. Performs other duties as assigned.

MINIMUM QUALIFICATIONS:
Education/Specialized Training/Licensure: Bachelor’s Degree in Business. Public Health, Mathematics or related field.  Master’s degree, MBA or MHA preferred.

Work Experience:

• Two  (2)  years of work experience in Analytics, Reporting, Business Intelligence or related area preferred.  
  
• Two (2) years in Healthcare highly preferred.
  
• Experience working on Commercial Risk Adjustment  is preferred   
  
• Experience with SQL query writing and using reporting tools (e.g. MS Excel, SQL Reporting Services, Power BI etc.).
  
• Basic Medical knowledge of ICD9 and ICD10 codes preferred.
  

Software Operated: Microsoft Office (Word, Outlook, Excel)

Other Requirements
– Knowledge of data analysis methodology, understanding of data analytic tools and good communication and documentation skills.
– Experience developing actionable reporting using key metrics communicated in an easy to understand manner.

SPECIAL REQUIREMENTS: 

Communication Skills:
Above Average Verbal (Heavy Public Contact)
Writing /Composing: Correspondence / Reports

Other Skills: Analytical, Mathematics, Medical Terminology, MS Word, MS Excel

 Clipped from: https://jobs.harrishealth.org/risk-adjustment-analyst-community-health-choice/job/19156355?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Resp & Qualifications

PURPOSE:
Provide direct support to ensure that patients move through the system and receive the treatment and services they require. Incumbent will work to bring all aspect’s of a patient’s care together including follow-up appointments, record management as well as care management.


ESSENTIAL FUNCTIONS:

• Establish and promote collaborative working relationships with Care Managers, Social Workers and Nurses.
  
• Assists in referral process by transmitting required patient documentation and verifies that facility received documentation.
  
• Prepare, complete and distribute information packets. Initiate process to follow-up for any information missing.
  
• Facilitate effective exchange of information with facility liaisons, home care liaisons and suppliers.
  
• Assist in obtaining authorizations for transition to next level of care
  
• Provide clerical and support functions to Care Management staff members.
  

QUALIFICATIONS:


Education Level: High School Diploma


Experience: 3 years related administrative and/or health insurance experience.


Knowledge, Skills and Abilities (KSAs)

• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
  

 
 

Department

Department: DC Medicaid – Government Program

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

#LI-LY1

 
 

Clipped from: https://www.glassdoor.com/job-listing/care-manager-assistant-dc-medicaid-carefirst-bluecross-blueshield-JV_IC1138213_KO0,34_KE35,65.htm?jl=1008105882472&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

List of Jobs and Events

 
 

Care Manager (RN) (Medicaid)

MetroPlus Health Plan New York, NY Full-Time

Empower. Unite. Care.

 

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

About NYC Health + Hospitals

 

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth’s network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

The primary goal of the Care Manager is to optimize members’ health care and delivery of care experience with expected cost savings due to improved quality of care. This is accomplished through engagement and understanding of the member’s needs, environment, providers, support system and optimization of services available to them. Care Manager is expected to assess and evaluate member’s needs, be a creative, efficient and resourceful problem solver. In collaboration with the members’ care team, a plan of care with individualized goals and interventions is developed, implemented and outcomes evaluated.

Job Description

 

• Address member’s problems and needs: clinical, psychosocial, financial, environmental
  
• Provide services to members of varying age, risk level, clinical scenario, culture, financial means, social support, and motivation
  
• Engage members in a collaborative relationship, empowering them to self-manage their physical, psychosocial and environmental health to improve and maintain lifelong well being
  
• Prepare member-oriented plan of care with member, caregivers, and health care providers, integrating concepts of cultural sensitivity and privacy practices
  
• Participate in interdisciplinary rounds
  
• Ensure plans of care have individualized goals and interventions
  
• Communicate plan of care to Primary Care Physician
  
• Address gaps in care with the member and provider
  
• Address members social determinants of health issues
  
• Link members to available resources
  
• Provide care management support during Transitions of Care
  
• Ensure member/caregiver understanding as it relates to language barriers, stress reaction or cognitive limitations/barriers
  
• Train member on relevant chronic diseases, preventive care, medication management (medication reconciliation and adherence), home safety, etc.
  
• Provide Complex care management including but not limited to; ensuring access to care, reducing unnecessary hospitalizations, and appropriately referring to community supports
  
• Advocate for members by assisting them to address challenges and make informed choices regarding clinical status and treatment options
  
• Employ critical thinking and judgment when dealing with unplanned issues
  
• Maintain knowledge of Chronic Conditions and use job aids as a guidance
  
• Maintain accurate, comprehensive and current clinical and non-clinical documentation in DCMS, the Care Management System
  
• Comply with all orientation requirements, annual and other mandatory trainings, organizational and departmental policies and procedures, and actively participate in evaluation process
  
• Maintain professional competencies as a Care Manager
  
• Other duties as assigned by Manager
  

Minimum Qualifications

 

• Background: Registered Nurse, Bachelor’s Degree in Nursing required
  
• An equivalent combination of training, educational background, and experience in related fields such as hospital, home care, ambulatory setting and educational disciplines. Prior experience in Care Management in a health care and/or Managed Care setting preferred
  
• Proficiency with computers navigating in multiple systems and web- based applications
  
• Confident, autonomous, solution driven, detail oriented, high standards of excellence, nonjudgmental, diplomatic, resourceful, intuitive, dedicated, resilient and proactive
  
• Strong verbal and written communication skills including motivational coaching, influencing and negotiation abilities
  
• Time management and organizational skills
  
• Strong problem-solving skills
  
• Ability to prioritize and manage changing priorities under pressure
  
• Must know how to use Microsoft Office applications including Word, Excel, and PowerPoint and Outlook.
  
• Ability to proficiently read and interpret medical records, claims data, pharmacy, lab reports and prescriptions required
  
• If needed, ability to travel within the MetroPlus service area to participate in facility visits, community events, home visits or other community meetings, including conferences.
  
• Registered Nurse or LMSW/LCSW with current NYS license
  

Professional Competencies:

• Integrity and Trust
  
• Customer Focus
  
• Functional/Technical Skills
  
• Written/Oral Communications
  

Recommended Skills

• Attention To Detail
  
• Certified Nurse Practitioner
  
• Claim Processing
  
• Clinical Works
  
• Coaching And Mentoring
  
• Communication
  

 
 

Clipped from: https://www.careerbuilder.com/job/J3Q1R56BD8TTF59QRNX?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

By applying a Career Builder account will be created for you. Career Builder’s Terms & Conditions and Privacy Policy will apply.

Great sales are the result of solid purpose, conviction and pride – pride in your ability and your product. UnitedHealth Group offers a portfolio of products that are greatly improving the life of others. Bring along your passion and doyour life’s best work.(sm)

You want to do work that really matters. We want to bring more health resources and better solutions to the most vulnerable and least served members in our communities. This sounds like the perfect match. This Medicaid Sales Managercan work with state and federal government agencies, physicians and other providers, to bring greater care to more than three million people. Make a difference in the lives of those in your own community and a career with UnitedHealthcare Community Plan will allow you to do just that!

As the Medicaid Sales Manager you will provides sales leadership and growth strategies to the sales team for the Medicaid product. You will also implement a sales process that meets state Medicaid regulations and ensures Medicaid beneficiaries understand the product they are purchasing from the sales and marketing staff.

If you are located in Buffalo, NY, you will have the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities:

• Organizes and leads the sales staff’s efforts to ensure both compliance with Medicaid standards and that sales goals are met
  
• Recruits qualified staff, provides for their training and development. Sets performance expectations and goals, evaluates performance results, provides feedback to staff members and administers appropriate rewards
  
• Fosters a cohesive and supportive team environment, which promotes the good of the group and the growth of the individual
  
• Designs and executes a sales plan that includes strategies and revising strategies as dictated by market changes, sales results and other factors
  
• Assists in uncovering market niches and actively pursues growth opportunities
  
• Objectives are met within established spending limits
  
• Achieves predetermined membership objectives through implementation of sales strategies
  
• Monitors and maintains market intelligence on competition
  
• Monitors sales production and develops action plans with Sales Team to ensure goals are being met
  
• Represents the company as a spokesperson when addressing key organizations. Works with company representatives on product issues and provider network issues
  
• Continues to enhance and maintain a solid knowledge of Medicaid regulations, the managed care industry, the competitive environment, pertinent legislation, etc.
  
• Builds productive community relationships
  
• Creates and executes an annual marketing plan
  
• Attends sales seminars, workshops and reads relevant publications
  

Youll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Undergraduate degree or equivalent years of experience
  
• 3+ years successful sales, business development or marketing experience in insurance or related field
  
• 3+ years professional experience leading, supervising, coaching and mentoring a fast-paced, goal driven team
  
• MS Office proficiency (Outlook, Word, Excel, PowerPoint)
  
• Ability to travel up to 50% of the time within this Buffalo, NYsales service area
  
• Valid driver’s license and insured & reliable vehicle
  
• Live within a commutable distance to cover this assigned Buffalo, NY market area
  
• Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation
  

Preferred Qualifications:

• Bilingual
  
• Experience supervising, coaching and mentoring a sales team
  
• Successful, proven track record for selling Medicare, Medicaid or managed care products
  
• Managed care experience
  
• Established community contacts within assigned NY sales territory
  

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment

Careers with UnitedHealthcare.Let’s talk about opportunity. Start with a Fortune 5 organization that’s serving more than 85 million people already and building the industry’s singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they’re found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that’s second to none. This is no small opportunity. It’s where you can doyour life’s best work.(sm)

*All Telecommuters will be required to adhere to UnitedHealth Groups Telecommuter Policy.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug – free workplace. Candidates are required to pass a drug test before beginning employment.

 
 

Clipped from: https://www.sonicjobs.com/us/jobs/Dallas/job?l=62abf055e17e3d52f7eebec5&utm_medium=xml&utm_source=clickcast&ccuid=41157727020-17759

The State Personnel System is an E-Verify employer. For more information click on our E-Verify Website.

Requisition No: 705889 

Agency: Agency for Health Care Administration

Working Title: 68064934 – MEDICAL/HEALTH CARE PROGRAM ANALYST

Position Number: 68064934 

Salary:  $1,659.66 – $2,157.56 Bi-Weekly 

Posting Closing Date: 09/06/2022 

Agency Overview:

 
 

The Agency for Health Care Administration (AHCA) is Florida’s chief health policy and planning entity. The Agency is responsible for the oversight and administration of the Florida Medicaid program, the licensure and regulation of nearly 50,000 health care facilities, and empowering consumers through health care transparency initiatives.

 
 

Under the direction of Agency Secretary Simone Marstiller, the Agency is focused on advancing Governor DeSantis’ vision for Florida’s health care system to be the most cost-effective, transparent, and high-quality health care system in the nation.

 
 

The Medicaid program provides low-income families and individuals with access to health care.  If you have a desire to use your talent and skills at an organization that provides critical services to millions of individuals and families across the state, AHCA invites you to apply to become an essential member of our team. As one of Florida’s leading state agencies, AHCA’s diverse workforce community of more than 1,400 employees is proud of its efforts to serve the people of Florida.

 
 

Agency Objectives:

 
 

COST-EFFECTIVE

Leveraging Florida’s buying power in delivering high quality care at the lowest cost to taxpayers.

 
 

TRANSPARENT

Supporting initiatives that promote transparency and empower consumers in making well informed healthcare decisions.

 
 

HIGH QUALITY

Emphasizing quality in all that we do to improve health outcomes, always putting the individual first.

 
 

Position Overview:

 
 

This is an exciting opportunity to help shape the quality of health care in Florida. We are seeking to hire a Medical/Health Care Program Analyst who desires to work to enhance the delivery of health care services through the Florida Medicaid Program.  This position requires a candidate who is creative, flexible, innovative, and who will thrive in a fast-paced, team-based work environment.

 
 

This position is located in the Bureau of Medicaid Policy. Medicaid Policy is responsible for the development, coordination, and implementation of Florida Medicaid program policies, including: all Medicaid federal authorities (e.g., the Florida State Plan, 1115 waivers and home and community-based waivers), administrative rules, coverage policies, managed care plan contracts, bill analyses, drug utilization review boards, preferred drug lists, supplemental rebate contracts, and KidCare/Title 21. 

 
 

This position is responsible for organizing, supporting project activities and facilitating project teams; organizing and supporting rulemaking processes, preparing reports and presentations; analyzing service utilization data and population health data; analyzing and developing fiscal impact statements on proposed program revisions; preparing legislative budget requests and proposals; preparing bill analysis; researching state and federal laws that govern the Medicaid program; and representing the Agency in local, state, and national meetings.

 
 

Research

The incumbent shall:

Maintain up-to-date knowledge concerning all aspects of the Florida Medicaid program, including federal regulations, state statutes, administrative rules, and the Florida Medicaid State Plan.

Maintain up-to-date knowledge of health care and relevant industry trends that may have an impact on Florida Medicaid or may inform policy development activities.

Remain informed about the operations of the Medicaid fiscal agent, including Medicaid claims process, billing procedures, reimbursement methodologies, encounter submissions, and provider enrollment.

Remain informed about Medicare policies, national Medicaid-related research and demonstration projects, Medicaid medical assistance program innovations for general and special populations, and alternative financing and service delivery systems models.

Conduct research on assigned topics, including, but not limited to performing a review of peer-reviewed research articles, federal and state laws, other reliable sources of evidence, the Medicaid State Plan, Agency communications, State Medicaid Director Letters, and vendor contracts.

 
 

Program Planning and Analysis

The incumbent shall:

Analyze health care/program related information (including alternative financing and reimbursement strategies) in order to determine the effect on the Florida Medicaid program and compliance with federal and state laws.

Assist in the analysis and development of programmatic and fiscal impact statements based on proposed federal/state program or policy changes.

Prepare reports of research findings, including synthesizing complex and/or large amounts of information into a useful format and presentation.

Assist in the development of legislative budget requests and program proposals.

Assist in the development of grant proposals.

Assist in the completion of legislative reports, including collection of necessary data elements.

Assist in the development and implementation of program designs, projects, and/or plans in order to meet bureau goals/priorities.

 
 

Policy Development

The incumbent shall:

Develop and maintain program policies and procedures under the Florida Medicaid program to ensure that programs operate in accordance with the goals and objectives of the Agency, state and federal laws, rules, regulations, and guidelines.

Assist in the development of policy language for: the Medicaid managed care report guide, Medicaid contracts and amendments; Dear Managed Care Plan letters, contract interpretations, policy transmittals, and provider alerts.

Track and monitor the routing and approval of all policy documents to ensure timely completion and adherence to Agency established deadlines.

 
 

Communication

The incumbent shall:

Assist in the development of training and providing technical assistance to ensure consistency in service/program operation and conformity with goals and objectives of the Agency, state and federal laws, rules, regulations, and guidelines.

Develop, coordinate, and implement statewide program training plans.

Identify and document training needs.

Design and evaluate training programs and materials.

Conduct statewide and local trainings, as required.

Provide technical assistance regarding service/program policies and procedures.

Provide consultation through the accurate presentation of data and other service/program information.

Participate on behalf of the Agency in local, state, or national meetings, conferences, workshops, and seminars related to the Florida Medicaid program.

Prepare presentations materials, as assigned.

 
 

Contract Management

The incumbent shall:

Perform contract management activities in accordance with goals and objectives of the agency and state and federal laws, rules, regulations, and guidelines.

Develop and execute provider contracts addressing standard contract documents, services to be provided, manner of service provision, method of payment, and special provisions.

Process, inspect, review, and approve deliverables, and invoices for payment.

Track and monitor provider expenditures.

Maintain appropriate contract files and records.

Carry out other necessary contract management activities.

 
 

All applicants must ensure that all employment and detailed information about work experience is listed on your applicant profile and/or resume (including dates of service, reason for leaving, military service, self-employment, job-related volunteer work, internships, etc.) and that gaps in employment are explained.  Applicants who do not provide all information necessary to meet the minimum requirements, will not be considered for this position.

 
 

Benefits of Working for the State of Florida:
Working for the State of Florida is more than a paycheck. The State’s total compensation package for employees features a highly competitive set of employee benefits including:


     •         State Group Insurance Coverage Options, including health, life, dental, vision, and other  supplemental insurance options;
     •         Flexible Spending Accounts;
     •         State of Florida retirement options, including employer contributions;
     •         Generous annual and sick leave benefits;
     •         9 paid holidays a year and 1 Personal Holiday each year;
     •         Career advancement opportunities;
     •         Tuition waiver for courses offered by Florida’s nationally ranked State University System ;
     •         Training and professional development opportunities;
     •         And more!
 

For more information about the Bureau of Medicaid Policy, please visit our website at http://ahca.myflorida.com/Medicaid/index.shtml.

 
 

Join us at the Agency for Health Care Administration in fulfilling our mission to provide “Better Health Care for all Floridians.”

 
 

KNOWLEDGE, SKILLS, AND ABILITIES

Ability to direct and coordinate the planning and implementation of operational and program reviews and program monitoring activities.

Ability to utilize problem-solving techniques.

Ability to understand and apply applicable rules, regulations, policies, and procedures pertaining to a health services program.

Ability to prioritize workload.

Ability to develop various reports.

Ability to design, develop and implement research models.

Ability to manage a health services program.

Ability to assess budgetary needs.

Ability to collect and analyze financial data.

Ability to formulate policies and procedures.

Ability to plan, organize and coordinate work activities.

Ability to communicate effectively.

Ability to establish and maintain effective working relationships with others.

Ability to travel with or without accommodations.

 
 

MINIMUM QUALIFICATIONS REQUIREMENTS

One year of experience developing health care related policies

One year of technical writing experience

One year of experience managing complex assignments

 
 

A bachelor’s degree from a college or university is preferred and can substitute for the required experience.

Two years of professional experience in program planning, program research, or program evaluation is preferred.

 
 

Please note a skills test will be required.

 
 

LICENSURE, CERTIFICATION, OR REGISTRATION REQUIREMENTS

N/A

CONTACT:  LEKIEVA CAMPBELL (850) 412-4210

The State of Florida is an Equal Opportunity Employer/Affirmative Action Employer, and does not tolerate discrimination or violence in the workplace.

Candidates requiring a reasonable accommodation, as defined by the Americans with Disabilities Act, must notify the agency hiring authority and/or People First Service Center (1-866-663-4735). Notification to the hiring authority must be made in advance to allow sufficient time to provide the accommodation.

The State of Florida supports a Drug-Free workplace. All employees are subject to reasonable suspicion drug testing in accordance with Section 112.0455, F.S., Drug-Free Workplace Act.

VETERANS’ PREFERENCE.  Pursuant to Chapter 295, Florida Statutes, candidates eligible for Veterans’ Preference will receive preference in employment for Career Service vacancies and are encouraged to apply.  Certain service members may be eligible to receive waivers for postsecondary educational requirements.  Candidates claiming Veterans’ Preference must attach supporting documentation with each submission that includes character of service (for example, DD Form 214 Member Copy #4) along with any other documentation as required by Rule 55A-7, Florida Administrative Code.  Veterans’ Preference documentation requirements are available by clicking here.  All documentation is due by the close of the vacancy announcement. 

 
 

 
 

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Centene CorporationLong Island City, NY

• You could be the one who changes everything for our 26 million members.
  
• Centene is transforming the health of our communities, one person at a time.
  
• As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.
  
• Position Purpose: Oversee the product development and management of health and wellness products for the Medicaid (and other government programs) market.
  
• Design, develop, implement, and manage new and existing products from initial conception through service delivery
  
• Lead new product development efforts and cross-functional teams to develop and execute detailed project plans, outline workflows, sales and marketing collateral content, staffing models and product pricing, and client reporting specifications
  
• Monitor market trends to identify new product opportunities or enhancements to existing products
  
• Review product performance and outcomes and make recommendations for program improvements
  
• Respond to product inquires and assess new product requests
  
• Participate in the development of business strategy for the Medicaid market
  
• Ensures legal and regulatory compliance of new products and product enhancements
  
• Conduct training sessions for various internal teams on products
  
• Education/Experience: Bachelor’s degree in Communications, Business Administration, or related field.
  
• 5+ years experience with health care or Medicaid product development/management, marketing, or project management in a managed care or insurance environment.
  
• Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
  
• The above responsibilities will apply to the oversight of the Marketplace and Essential Health plan products for Fidelis Care.
  
• Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.
  
• Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different.
  
• All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
  
• Director, Product Development & Management (Medicaid)
  
• Long Island City, New York
  

Stand out and contact Centene Corporation directly

Updated 2 days ago

 
 

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Director of Medicaid

Oregon, Washington, Utah and Idaho (remote work available in these states)

Primary Job Purpose

The Director of Medicaid is the voice of Medicaid internally and externally reporting to the SVP, Government Programs. The Director of Medicaid is accountable for the Profit and Loss of the line of business. This leader is responsible for the strategy, business cases development and implementation of Medicaid in one or all of our four states. This includes overall performance of the market Medicaid line of business program, a focus on financial performance and membership growth. Oversees all aspects of market Medicaid programs, state contracting arrangements, product development, compliance with State and Federal Policies and requirements and partnerships with other divisions. Strategically builds, manages and sustains external business relationships, particularly with state and local regulators. Accountable for product development, administrative processes, interdepartmental communication and regulatory requirements. Develops an annual strategic plan and updates executive leadership on strategic issues/development, business performance and progress against objectives. Demonstrated passion and creativity in developing models of care serving low-income vulnerable populations.

General Functions and Outcomes

The position is responsible for the customer experience, achieving membership growth targets, overseeing & developing the Medicaid product portfolio and developing/executing market Medicaid strategy based on state and CMS requirements, national standards and alignment with overall national and market strategy. This position incorporates care delivery requirements into strategy and develops a strong partnership with the medical group and health plan delivery system.

Normally to be proficient in the competencies listed above:

Minimum 10 years of relevant experience in a Medicaid managed care organization. Minimum 7 years of management experience. Minimum 5 years in product line management to special populations. Bachelor’s degree or 4 years relevant experience.

Minimum Requirements

The Director, Medicaid must have a strong background working with Medicaid and/or Special Populations and unique health care needs. Must be a decisive, results-oriented leader of people, be able to work in a highly matrixed environment and have strong collaborative skills. Additional competencies include:

• Understanding of state and federal Medicaid framework and regulatory requirements
  
• Excellent negotiation skills, verbal/written communication skills
  
• Strong analytical and strategic planning skills
  
• Excellent public presentation skills
  
• Strong persuasive and interpersonal skills
  
• Product and Program development skills
  
• Knowledgeable of Medicaid health care delivery systems
  
• Knowledgeable of current trends in care management and industry related to care delivery to Medicaid population
  
• Demonstrated ability to build effective partnerships and influence others who may have different perspectives
  

FTE’s Supervised

1-5 direct reports

15-20 total

Work Environment

Work is primarily performed remotely

Travel may be required, locally or out of state

May be required to work outside normal hours

Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We’ve been here for members for 100 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.


If you’re seeking a career focused on making the health care experience simpler, better, and more affordable for people and their families, consider joining our team at Cambia Health Solutions. Cambia is a total health solutions company that is deeply rooted in a 100-year legacy of transforming the industry and the way people experience health care. We had our beginnings in the logging communities of the Pacific Northwest as innovators in helping workers afford health care. That pioneering spirit has kept us at the forefront as we build new avenues to improve access to and quality of health care for the future. Cambia is committed to delivering a seamless, personalized health care experience for the next 100 years.

This position includes 401(k), healthcare, paid time off, paid holidays, and more. For more information, please visit

www.cambiahealth.com/careers/total-rewards

.

We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.

If you need accommodation for any part of the application process because of a medical condition or disability, please email

CambiaCareers@cambiahealth.com

. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our

Privacy Policy

. As a health care company, we are committed to the health of our communities and employees during the COVID-19 pandemic. Please review the policy on our

Careers

site.

 
 

Clipped from: https://www.glassdoor.com/job-listing/director-medicaid-cambia-health-solutions-JV_IC1151614_KO0,17_KE18,41.htm?jl=1007977829852&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Resp & Qualifications

PURPOSE:
Supervise and provides daily direction to multi-functional team members regarding training and development, policies, procedures, and work production quantity and quality. Functional areas may include but not limited to: installation, implementation, client support, client services, client administration, customer service, enrollment and eligibility, claims processing, and call center operations. Reviews and resolves complex service issues not resolvable by subordinates.

ESSENTIAL FUNCTIONS:

• Supervise employee outcomes by training, assigning, scheduling, coaching, and counseling employees; communicating job expectations; planning, monitoring, and appraising job contributions; adhering to policies and procedures.
  
• Meets operational standards by contributing information to strategic plans and reviews; implementing production, productivity, quality, and customer-service; resolving problems; identifying system improvements.
  
• Maintains customer service objectives by monitoring daily operations; resolving claims that require manual review or technical support, enrollment or billing related customer issues. Consistently reviews systems and makes necessary adjustments where needed, including resources/staffing. Researches and resolves escalated calls, review and resolve complex claims that have not been resolved by Claims staff.
  
• Maintains and improves departmental operations by monitoring system performance; identifying and resolving operations problems; supervising process improvement and quality assurance programs; installing upgrades.
  
• Prepares call center, claims and or enrollment and billing performance reports by collecting, analyzing, and summarizing data and trends.
  
• Improves call center, claims and or enrollment and billing job knowledge by attending educational workshops.
  

SUPERVISORY RESPONSIBILITY:
This position manages 2-10 people.

QUALIFICATIONS:

Education Level: High School Diploma or GED.

Experience: 3 years related professional experience with demonstrated leadership skills. Must have proficiency in the service, claims or enrollment & billing area.

Preferred Qualifications: Bachelor’s Degree. 

• Familiar with the Market Prominence system
  
• Three – Five years of supervision experience
  
• Knowledge of Dual Eligible Special Needs Plans (DSNP)
  
• Ideal candidate will have experience with Membership Enrollment and/or Managed Health Care Experience 
  

Knowledge, Skills and Abilities (KSAs)

• Knowledge of call center operations, claims and/or enrollment and billing and work flows.
  
• Strong presentation skills.
  
• Highly proficient in Microsoft Office programs.
  
• Excellent communication skills both written and verbal.
  
• Ability to plan, review, supervise, and inspect the work of others.
  

Department

Department:MD Medicaid-Enrollment

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The associate must frequently talk and hear.  Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship.

#LI-LY1 

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