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Provider Contracting Executive- Ohio Medicaid | Humana

 
 

The Provider Contracting Executive initiates, negotiates, and executes physician, hospital, and/or other provider contracts and agreements for an organization that provides health insurance. The Provider Contracting Executive works on problems of diverse scope and complexity ranging from moderate to substantial.

 
 

Responsibilities

The Provider Contracting Executive for Ohio Medicaid will communicate contract terms, payment structures, and reimbursement rates to providers. You will be responsible for Ohio Medicaid compliance with network adequacy standards. Maintains familiarity with Ohio Medicaid fee schedules and analyzes comparable Plan pricing guidelines. Ensures capitation, provider rosters, and RHC/FQHC reports are monitored and strategies are developed and plans are implemented to address outliers. Remains current in all aspects of Federal and State rules, regulations, policies and procedures and creates or modifies departmental policies to reflect changes. You will analyze financial impact of contracts and terms. Maintain contracts and documentation within a tracking system. Will identify and recruiting providers based on network composition and needs. Advise executives to develop functional strategies (often segment specific) on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision. Uses independent judgment requiring analysis of variable factors and determining the best course of action.

               
 

Required Qualifications

  • Bachelor’s degree
  • Knowledgeable of Ohio Medicaid compliance with network adequacy standards
  • Experience negotiating fee for service & capitated reimbursement methodologies for Hospital, Ancillary and Providers specific to Ohio Medicaid methodologies
  • Experience communicating the implementation of capitation payments, provider rosters, and RHC/FQHC reports to internal load teams, able to address outliers with provider community
  • 5 or more years of progressive network management experience including hospital contracting and network administration in a healthcare company
  • 2 or more years of project leadership experience
  • Minimum 1-2 years Ohio Medicaid experience
  • Extensive provider contracting skills, including contract preparation and implementation, financial analysis and rate proposal development
  • Excellent written and verbal communication skills and experience presenting to varied audiences
  • Ability to manage multiple priorities in a fast-paced environment
  • Knowledge of Microsoft Office applications
  • Must be passionate about contributing to an organization focused on continuously improving consumer experiences

 
 

Preferred Qualifications

  • Master’s Degree
  • Experience with ACO/Risk Contracting
  • Experience with Value Based Contracting

 
 

Additional Information

This position is considered “remote/work at home”, however, you must live in Ohio to be considered for this opportunity.

Work at Home/Remote Requirements Must ensure designated work area is free from distractions during work hours and virtual meetings Must provide a high-speed DSL or cable modem for a workspace (Satellite and Hotspots are prohibited). A minimum standard speed of 10×1 (10mbs download x 1mbs upload) for optimal performance of is required

 
 

Scheduled Weekly Hours

40

 
 

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Posted on

Anthem Government Relations Director

 
 

Description

SHIFT: Day Job


SCHEDULE: Full-time

Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.

This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America’s leading health care companies and a Fortune Top 50 Company.

The Government Relations Director is responsible for developing and implementing strategies to advocate enterprise and state specific legislative and regulatory positions in legislative and/or regulatory environments. Primary duties may include, but are not limited to:

  • Develops and implements strategies to advocate enterprise and state specific legislative and regulatory positions to support business goals and objectives.
  • Represents the enterprise and its specific businesses in advocacy efforts.
  • Establishes and maintains strong relationships with legislators, regulators, other policymakers and their staff.
  • Develops strategies for utilizing PAC and/or corporate political contributions.
  • Maintains coalitions and target grassroots capabilities.
  • Consults with SBUs and CEEs to inform and support business planning processes and proactively raise and address issues of concern.
  • Makes internal and external written and oral presentations on behalf of the company.
  • Develops and carries out tactics and strategies to influence trade associations and other advocacy organizations.
  • Generally works with legislative sessions of less than 6 months and/or in less complex legislative and/or regulatory environments.

Qualifications

Requires a BA/BS in a related field; 8 years of legislative, regulatory, political, public affairs or industry experience; or any combination of education and experience, which would provide an equivalent background.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

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Posted on

Lead Utilization Management Generalist

 
 

 
 

Found in: beBee S US

Description:

Resp & Qualifications

Utilizing key principles of utilization management, the Utilization Review Specialist will perform prospective,
concurrent and retrospective reviews for authorization, appropriateness of care determination and benefit coverage.
Leveraging clinical expertise and critical thinking skills, the Utilization Review Specialist, will analyze clinical
information, contracts, mandates, medical policy, evidence based published research, national accreditation and
regulatory requirements contribute to determination of appropriateness and authorization of clinical services both
medical and behavioral health.
ESSENTIAL FUNCTIONS
Weight Essential Functions
50% Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit
information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine),
Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other
accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinical
trials.Gov, National Institute of Health, etc.) Follows NCQA Standards, CareFirst Medical Policy, all
guidelines and departmental SOPS to manage their member assignments. Understands all CareFirst lines
of business to include Commercial, FEP, and Medicare primary and secondary policies.
30% Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including
high cost/high dollar services to support decisions and recommendations made to the medical directors.
Collaborates with medical directors, sales and marketing, contracting, provider and member services to
determine appropriate benefit application. Applies sound clinical knowledge and judgment throughout the
review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting,
providers and facilities. Follows member contracts to assist with benefit determination.
20% Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for
alternative settings for care. Researches and presents educational topics related to cases, disease entities,
treatment modalities to interdepartmental audiences.
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The
requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable
accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education Level: Bachelor’s Degree
Education Details: Nursing
Experience: 5 years Clinical nursing experience
2 years Care Management
In Lieu of Education
In lieu of a Bachelor’s degree, an additional 4 years of relevant work experience is required in addition to the
required work experience.
Preferred Qualifications
Working knowledge of managed care and health delivery systems.
Thorough knowledge of CareFirst clinical guidelines, medical policies and accreditation and regulatory standards
Working knowledge of CareFirst IT and Medical Management systems, familiarity with

 
 

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Posted on

Clinical Outreach Associate

Description:

Serves as a point of contact for health care services and referrals for members with medical and behavioral health needs. Reviews encounter forms/claims to identify all potential case management service needs and collaborates with RN case managers, e Associate, Clinical, Outreach, Management, Health, Medical

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Posted on

Medical Proposal Writer Sr


Location:


This is a Work-At-Home position.  However, the selected candidate must live within commutable distance from an Anthem office.

The Proposal Writer Sr. is responsible for writing strategic, highly customized, complex proposal responses to win and retain existing business. Primary duties may include, but are not limited to:
Develops written solutions incorporating complex, custom win strategies based on local market needs, leveraging best practices, brand standards, innovative ideas, and reviewer insights. Identifies and creates standard content for the proposal database and edits content as needed. Aligns multiple written communication efforts with the overall Anthem messaging and goals. Partners with Subject Matter Experts (SMEs) to transfer knowledge, develop new solutions, obtain direction and create alternative solutions.

Researches, recommends and develops creative approaches and solutions to content. Serves as a key communications resource for business leaders and collaborates across various areas to support enterprise-wide selling initiatives.


Qualifications


Requires a BA/BS degree; 5 years of health care specific proposal writing experience; or any combination of education and experience, which would provide an equivalent background.


Experience working in a heavily matrixed environment and proven relationship-building skills required. Expert level experience in managing large-scale proposals or communication initiatives including writing and reviewing healthcare bids for healthcare companies in a deadline-driven environment required.


Applicable to Colorado Applicants OnlyAnnual Salary Range*: $84,084 – $126,126


Actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level.  

* The hourly or salary range is the range Anthem in good faith believes is the range of possible compensation for this role at the time of this posting.  The Company may ultimately pay more or less than the posted range. This range is only applicable for jobs to be performed in Colorado. This range may be modified in the future.  

No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits or any other form of compensation and benefits that are allocable to a particular employee remains in the Company’s sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.


We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.


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Posted on

MEDICAL DIRECTOR – MEDICAID, UTILIZATION REVIEW | Presbyterian Healthcare Services

 
 

 
 

Overview

The Medical Director – Centennial Care will join an established team that is shaping the future of Presbyterian’s Medicaid plan and the evolution of the State of New Mexico’s Medicaid program.

Presbyterian Health Plan – Presbyterian Healthcare Services’ insurance entity – includes Medicaid and Medicare insurance plans, as well as multiple commercial options. The Medicaid plan – Presbyterian Centennial Care – currently serves more than 300,000 of New Mexico’s Medicaid members. New Mexico named the program “Centennial Care” in 2012 to honor one hundred years of statehood.
The scale and diversity of the Medicaid population affords unusual opportunities to effect change. Presbyterian leadership work one-on-one with New Mexico HSD personnel who are very open to initiatives, pilot programs, etc. that align with Centennial Care goals.

The following list highlights the opportunities this position offers for professional, cultural, and personal growth:


  • Play an integral role within a fully integrated healthcare system.
  • Break new ground in medical cost management and population health management.
  • Support development and revisions to Medical Policies.
  • Assist in initiatives to ensure accessibility of quality, affordable care and coverage for PHPs customers and members.
  • Provide clinical leadership and promote best practices across the Presbyterian organization.
  • Manage relationships with providers across the state.
  • Support population health efforts, including a large population of vulnerable individuals in achieving their best health.
  • Support New Mexico in improving the health of its population.
  • Provide guidance and support for forward-thinking quality improvement initiatives.

Responsibilities

The Centennial Care Medical Director reports to the Presbyterian Health Plan (PHP) Senior Medical Director. S/he will be primarily responsible for performing medical necessity determinations in partnership with PHPs Utilization Management. The Medical Director is responsible for ensuring medical protocols and practice guidelines. This includes utilization management of health care services primarily with the prior authorization staff, participation in formulating complex care coordination, as well as peer-to-peer discussions with community clinicians. The Medical Director will also provide medical oversight, expertise, and leadership to ensure the delivery of cost-effective, quality healthcare services PHP members.


  • Leads ongoing identification, design, and development of clinical practice guidelines/disease management pathways, incorporating both national standards and local physician input.
  • Provides leadership in the education of members, providers, and PHS entities in the principles of coordination of care and utilization/resource/cost management, particularly as this relates to PHP.
  • Primary responsibility for and direction of PHP utilization management activities, including direction and support for nurses in prior authorization, concurrent and retrospective review, referral coordination, and case management activities.
  • Maintains effective liaison with provider groups in order to foster open communication and engender a collegial atmosphere in working toward a common goal: quality, cost effective health care.
  • Assists in identifying and addressing examples of inordinate variation in patterns of utilization, and guiding staff and providers to effective resolution.
  • Participates in development and implementation of an outcomes-oriented PHP Quality Management Program.
  • Assists in the development of strategic plans for addressing resource management concerns and opportunities.
  • Supports Delegated Groups through collegial educational efforts and facilitation of communication with these groups.
  • Monitors and assists in the implementation of a quality, cost effective pharmacy program.
  • Participates in all appropriate committee activities within the Quality committee structure.
  • Participates in relevant strategic and benefit planning sessions.
  • Insures compliance with HCFA, HSD, DOI and all other regulatory agencies.
  • Supports PHP in achieving and maintaining NCQA, HCFA, IPRO and all other accrediting requirements.
  • Helps to ensure the implementation of an effective information system which is relevant in measuring both quality and utilization outcomes.
  • Supports efforts of PHP in developing and distributing a severity-adjusted Physician Practice Profile.
  • Supports PHS-wide Health management activities designed to improve the health of those individuals, families, and communities we serve.
  • Performs other functions as required.

Qualifications

  • M.D. or D.O. degree, with board certification

  • Five years of clinical practice experience

  • Currently licensed to practice without restriction
  • Experience in a managed care setting strongly preferred

  • Experience in use of application of evidence-based clinical practice guidelines and resource, utilization, and cost management initiatives.
  • Requires detailed knowledge of medical management principles, including utilization management, case management, retrospective and concurrent review, and prior authorization, in terms of theories and practices both directly and to serve as the resource or educator to other practitioners.
  • Understanding of managed care environment.
    Experience with Medicare, Medicaid and state programs desirable. Familiarity with National Committee for Quality Assurance (NCQA) and with Health Plan Employer Data and Information Set (HEDIS) principles and requirements desirable.

Benefits

Benefits are effective day-one (for .45 FTE and above) and include:


  • Competitive salaries
  • Full medical, dental and vision insurance
  • Flexible spending accounts (FSAs)
  • Free wellness programs
  • Paid time off (PTO)
  • Retirement plans, including matching employer contributions
  • Continuing education and career development opportunities
  • Life insurance and short/long term disability programs

About Us

Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state’s largest private employer with approximately 14,000 employees.

Presbyterian’s story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans.
We are part of New Mexico’s history – and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.

About New Mexico


New Mexico’s unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque’s International Balloon Fiesta, Los Alamos’ nuclear scientists, Roswell’s visitors from outer space, and Santa Fe’s artists, and you get an eclectic mix of people, places and experiences that make this state great.

Cities in New Mexico are continually ranked among the nation’s best places to work and live by Forbes magazine, Kiplinger’s Personal Finance, and other corporate and government relocation managers like Worldwide ERC.
New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it’s all available among our beautiful wonders of the west.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses
#JB123

 
 

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Posted on

Dental / Vision Growth Strategy Lead

Description:

Job Description
The Dental, Vision Voluntary Growth Strategy Lead will grasp marketing, client relationships and sales in a holistic way to leverage all tools, techniques, and their expertise for growth in Medicare/Medicaid (sales or client relations) to accomplish our strategic growth goals. Responsibility for driving year over year growth across all products.

Required Qualifications

– Drives the cross functional coordination deepen penetration and increase cross sell opportunities and reduce non-value-added activities encumbering growth initiatives.
– Collaborates with Medicare, Medicaid and network teams on the annual growth planning process , driving and developing long-range strategic plans, objectives, and tactics for our client portfolio’s while ensuring alignment & inclusion of our company’s aspirations to introduce new and innovative products.
– Participates in the development of marketing/sales strategies and processes, liaising with key stakeholders.
– Cultivates long term key stakeholder prospect relationships and positions our company as optimal solution before and when an opportunity develops.
– Provide strategic direction, leadership and support to sales and service staff and consultative services to customers to achieve sales, service and retention goals.
– Formulates strategic decisions by bridging insights (data) and product strategies to guide creative direction for increased revenue and client loyalty.
– Develops actionable strategies, and dashboards to gain a competitive advantage and determine best means to communicate and collaborate with existing clients.
– Anticipates and identifies challenges and builds solutions.

Preferred Qualifications

– 7-10 years of experience in Business Development, direct sales or Client Management Leadership.
– Proven experience leading transformational change in a competitive consumer product market.
– Demonstrate ability to define and deliver on growth strategy and distribution channel optimization across multiple geographies.
– Demonstrate superior analytical, quantitative and problem-solving skills.
– Ability to develop and execute strategy
– Ability to turn quantitative and qualitative data insights into actionable marketing recommendations and able to tell the story.
– Track record of success driving outcomes across an organization with multiple stakeholders.
– Strong affinity understanding of target audiences, needs and sales management.
– Builds credibility and trust across the organization to drive change by challenging conventional thinking.
– Client facing role

Education

Bachelor’s degree or equivalent work experience

Business Overview

At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

20 hours ago

 
 

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Posted on

Medicaid/Medicare Srvs Specialist III | Commonwealth of Kentucky

 
 

Medicaid/Medicare Srvs Specialist III

Pay Grade 15

Salary $3,230.84 Monthly

Employment Type

EXECUTIVE BRANCH | FULL TIME, ELIGIBLE FOR OVERTIME PAY | 18A | 37.5 HR/WK

Hiring Agency

Cabinet for Health & Family Services | Department for Medicaid Services

Location

275 East Main Street, 6W-B

Frankfort, KY 40621 USA

The agency may authorize the selected candidate to telecommute. The candidate may need to report to the office as needed. The agency may terminate or modify the telecommuting arrangement at any time.

Description

The Department for Medicaid Services (DMS), Division of Community Alternatives, Home and Community Based Services Branch provides services and support to elderly people and/or children to remain in or return to their homes provided through waiver programs. This opportunity will allow an individual to continue career growth by learning the various deliveries of waiver services through person directed services (PDS) and traditional agencies providing services to our waiver participants served under the Home and Community Services Branch. The agency may authorize the selected candidate to telecommute. The candidate may need to report to the office as needed. The agency may terminate or modify the telecommuting arrangement at any time.

The candidate will assist both participants, providers and other agencies by identify and resolving routine program issues. As well as conducting audits, monitoring and analyze trends and patterns identifying program deficiencies. Perform duties including but not limited to completing tasks the Medicaid Waiver Management Application (MWMA), Medicaid Management Information System (MMIS) and Benefind. Research complex issues related to Centers for Medicare and Medicaid Services (CMS), Cabinet for Health and Family Services and within the Department for Medicaid Services. Performs audits and program monitoring from the office, as well as provider locations to determine CMS/DMS program compliance. Represents the division and branch in meetings and reports information obtained to management.

Preferred Skills

  • Proficient at Microsoft Office products.
  • Preferred candidate will have experience in Medicaid or Medicare policy or other related health insurance administration/systems health care research, health care financial management, health care policy
  • Willing to work as a team
  • Excellent communication skills ability to critically think

Minimum Requirements


EDUCATION: Graduate of a college or university with a bachelor’s degree.


EXPERIENCE, TRAINING, OR SKILLS: Four years of experience in Medicaid or Medicare program administration, health insurance administration/systems, eligibility systems, health care research, health care planning, health care financial management, health care policy development, human service or health care administration, insurance billing and/or claims, or research, review, and analysis of legislation or regulations.


Substitute EDUCATION for EXPERIENCE: NONE


Substitute EXPERIENCE for EDUCATION: Experience in the above areas will substitute for the required college on a year-for-year basis. Current or prior military experience will substitute for the required college on a year for year basis. Prior military experience will only substitute if the individual received an honorable discharge, discharge under honorable conditions, or a general discharge.


SPECIAL REQUIREMENTS (AGE, LICENSURE, REGULATION, ETC.): NONE


Working Conditions


Incumbents working in this job title primarily perform duties in an office setting.


Probationary Period


This job has an initial and promotional probationary period of 6 months, except as provided in KRS 18A.111.


If you have questions about this advertisement, please contact April Lowery at April.Lowery@ky.gov.


An Equal Opportunity Employer M/F/D

 
 

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Posted on

Senior Actuarial Consultant (Cred)

Description:

Job Description
This position is responsible for actuarial support of the Louisiana Medicaid market, including pricing evaluation, reserving, forecasting and other analytical support as necessary. The actuarial team works closely with other functional areas, including Finance, Operations, Medical Management and Plan management.

#AetnaActuary


Required Qualifications

Existing proficiency with Microsoft Word, Excel Demonstrated analytical and computing skills. Demonstrated initiative and perseverance Excellent oral and written communications skills.

Preferred Qualifications

We are looking for individuals interested in pursuing their ASA/FSA designation(s). Progress in the exams towards the ASA designation.

Education

Degree in Actuarial Science / Statistics / Mathematics, or in Computer Science / Economics / Business / Finance / Physics / Engineering with a strong math background.

Business Overview

At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

21 hours ago

 
 

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