Author: MM_ADMIN

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Report finds western Iowa agency improperly billed Medicaid for some services

[MM Curator Summary]: An Iowa referral agency double-billed the state for services over a 4 year period.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

A special investigation by the state auditor’s office has found a non-profit in western Iowa was double-billing for some services.

Iowa Department of Public Health officials asked for the review of a non-profit called FAMILY, Inc. It links needy residents to a variety of government services for women, children and families in Pottawattamie and Mills Counties. The review centered on the organizations’s contracts with state agencies — one for home visits with pregnant women and families with young children and the other for a program called Early Childhood Iowa.

Auditors determined that over a four-year period, FAMILY, Inc. billed Medicaid for more than 20-thousand dollars in services already covered by the contracts. State Auditor Rob Sand said in the report that due to a lack of records, it was not possible to determine if improper billing happened before July 1, 2017. According to the auditor, the Iowa Department of Public Health adopted more cross-checks last year to ensure other providers aren’t double-billing for these same services.

A spokesperson for FAMILY, Inc. was not immediately available for comment when the special investigation by the state auditor’s office was released this morning.

 
 

Clipped from: https://www.radioiowa.com/2022/05/10/report-finds-western-iowa-agency-improperly-billed-medicaid-for-some-services/

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Mental Health Bill Aims to Sync Substance Use, Medicaid Agencies

[MM Curator Summary]: A new federal bill would specify monies to enforce existing MH parity rules.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

Mental health services would get a funding boost in bipartisan legislation set to be unveiled Tuesday that aims to improve coordination between agencies focusing on opioid addiction services and paying for treatment.

The measure, by Sens. Bill Cassidy (R-La.) and Chris Murphy (D-Conn.), would provide a path for ramping up existing health plans and coordination between the Substance Abuse and Mental Health Services Administration and the Centers for Medicare & Medicaid Services to better help individuals with serious mental illness.

According to a legislative overview document, the Mental Health Reform Reauthorization Act of 2022 would also authorize $25 million annually for five fiscal years for states to enforce existing mental health parity laws. The existing laws require that insurers cover mental health care to the same extent as other services.

Mental health has been a major focus for both parties in Congress as well as the White House, taking up much space in congressional hearings and administration policy pushes. House lawmakers on May 6 introduced legislation to reauthorize several federal health programs and require non-government plans to comply with mental health parity laws.

“I’m probably always willing to go further on parity, you know, enforcement than some Republicans are. And I’m always kind of sensitive to finding the middle ground when it comes to the way in which we enforce existing parity law,” Murphy told reporters last week.

Murphy also noted that “we’re sensitive to the appetite right now for a lot of new programs,” though noted skepticism from Sen. Richard Burr (R-N.C.) “about the utility of new programs.” Burr is the ranking member of the Senate Committee on Health, Education, Labor and Pensions, which deals with mental health matters.

The legislation would also re-up dollars for one of SAMHSA’s largest programs, the Community Mental Health Services Block Grant, and push for the CMS to coordinate better in serving young individuals earlier when they experience mental health troubles.

“Step by step by step, we want to make it so that the first psychotic episode a young person has is her last psychotic episode,” Cassidy said at a press event on the legislation.

Those eligible for SAMHSA grants to divert people with mental illness from incarceration would be protected from “destabilizing medication changes” under the bill, according to an overview document for the legislation. The bill would also support a SAMHSA program to help those suffering from mental illness and homelessness access housing.

 
 

Clipped from: https://news.bloomberglaw.com/pharma-and-life-sciences/mental-health-bill-aims-to-sync-substance-use-medicaid-agencies

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OH- Rollout of Medicaid reforms delayed

[MM Curator Summary]: All of the OH Medicaid reforms except OH Rise are on hold while the state deals with the PHE wind-down efforts.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

The projected launch date of Ohio’s revamped and reformed Medicaid managed care system will still be July – except this month, given a potential crisis where many may be kicked off Medicaid, the state pushed back most of the reforms to the end of this year.

“It seems like this new phased approach still allows them to move forward with everything, but in a way that is manageable…to maybe take smaller bites of the apple,” said Loren Anthes, who chairs Community Solutions’ Center for Medicaid Policy.

Medicaid, government-paid health insurance for more than 3 million low-income or disabled Ohioans, is typically the state’s largest expenditure totaling billions of dollars. The “next generation” system is the result of an extensive process that started in 2019, looking at ways to overhaul the system after years of issues and lack of reform.

According to the Ohio Department of Medicaid, one of those reforms will still be up and running in July. OhioRISE is a new coverage system to treat children with severe behavioral and mental problems so parents don’t have to give up custody.

But all the other more complicated changes, such as a single pharmacy benefit manager to prevent prescription drug “middlemen” from overcharging taxpayers, won’t happen until October at the earliest. The same applies to the two to three new health plan options entering the system: AmeriHealth Caritas, Humana, and Anthem Blue Cross and Blue Shield.

 
 

Why the delay?

The planned July launch date could coincide with the end of the federal government’s COVID-19 emergency declaration, which prevented states from kicking ineligible people off Medicaid. When that ends, almost everybody will have to go through eligibility checks – a daunting task for an understaffed system that could also leave Ohioans confused over if they still have health insurance.

Spreading the Medicaid reforms out to later in the year would prevent a disaster scenario where both the eligibility checks and the new reforms go awry at the same time, said Anthes, the Medicaid policy expert.

“It is important that the reforms and improvements embodied in the Next Generation program are not compromised with a hurried launch, or potentially confusing communications,” the Medicaid department said in a document sent to lawmakers.

Despite the later timeline, Medicaid participants still can choose to enroll into one of the new plan options now, said department spokesperson Lisa Lawless. They’ll just remain on their current health plan until the end of the year when the switch occurs.

Starting dates for the new system were pushed back before, and some lawmakers have been concerned with how long implementation has taken. But the department insists they are not rushed.

“Doing this correctly is more important than meeting an administratively imposed timeline,” it told lawmakers.

 
 

Clipped from: https://insurancenewsnet.com/oarticle/rollout-of-medicaid-reforms-delayed

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Anthem Announces Finalization of Integra Managed Care Acquisition

[MM Curator Summary]: Anthem completed the acquisition of another LTSS plan as part of its strategy to extend services further into the home of Medicaid members.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

The payer shared that it aims to enhance its government business with its acquisition of Integra as it pursues whole-person care.

 
 

Source: Getty Images

 
 

By Kelsey Waddill

May 06, 2022 – Anthem has finalized its acquisition of Integra Managed Care, the payer announced.

Integra is a managed care company that offers managed long-term care plans. The organization serves four areas in the state of New York: New York City, Nassau, Suffolk, and Westchester. It will provide services to Anthem members who have disabilities or who require long-term care.

Integra will join the major payer’s government business division. The acquisition is strategically focused on the public payer space: the addition of Integra will expand Anthem’s ability to serve Medicaid beneficiaries in New York.

“We’re pleased to complete this acquisition and work alongside our new colleagues as we continue to grow our Medicaid business and enhance the healthcare experience for all of our members,” said Felicia Norwood, executive vice president of Anthem’s government business division. 

“Anthem and Integra’s shared commitment to deliver high quality, comprehensive whole-health care across communities throughout New York ensures that our members will continue to receive the care and support services that they have come to expect.”

Integra serves 40,000 Medicaid members. Members receive support from a care management team that includes a social worker. Additionally, a care coordinator helps with arranging to meet the member’s long-term care needs.

Anthem did not release any financial information about the deal.

The payer announced its plans to acquire Integra in November 2021. Prior to Anthem’s acquisition, Integra was a wholly-owned indirect subsidiary of Personal Touch Holding Corporation.

“This acquisition aligns with our goal of growing Anthem’s Medicaid business, while serving our members with a comprehensive and coordinated approach to care,” Norwood said at the time of the original announcement.

In addition to expanding its government business division, Anthem has used acquisitions to enhance its home healthcare services capabilities. The payer announced plans to acquire myNEXUS in March 2021 and only a month later the deal was completed, as projected.

In both the acquisition of myNEXUS and the acquisition of Integra, executives at Anthem cited whole-person care as a key motivator.

For those with long-term care needs, whole-person care is critical, specifically for those living with a serious illness or in need of palliative care, a study from AHIP found. The aging population also brings this conversation to the forefront.

The study emphasized that case managers are key to providing holistic care for palliative care needs or for those who have serious illnesses. Such a role can help take on the burden of care planning, navigating benefits, and overall case management as well as communicating with caregivers. Additionally, case managers can provide support for social determinants of health needs.

All of these elements factor into a whole-person care approach for a person in long-term care.

In a study that Anthem commissioned, experts revealed that integrated health care benefits can be crucial for whole-person care as well. Such benefits bring together pharmacy needs with supplemental healthcare and additional benefits data in order to improve care coordination.

The acquisition of Integra intends to bolster the payer’s government business in Medicaid but also aims to enable better whole-person care options for members as they seek long-term care.

 
 

Clipped from: https://healthpayerintelligence.com/news/anthem-announces-finalization-of-integra-managed-care-acquisition

 
 

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OR- New Cancer Drug Access at Risk in Oregon Medicaid Proposal

[MM Curator Summary]: You can have faster cancer drugs or cost management. Not both.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

 
 

An Oregon proposal to exclude expensive drugs that received FDA fast-track approval from Medicaid coverage is alarming advocates for patients with cancer and other life-threatening diseases.

If approved, the proposal could limit access in Medicaid to promising treatments for patients with deadly conditions, and could encourage other states to similarly attempt to restrict access to get relief from rising drug costs, advocates say.

At issue are drugs approved under the Food and Drug Administration’s accelerated approval pathway, which emerged in the 1990s during the AIDS crisis as a way of speeding access to medications for patients with serious conditions and few, if any, treatment options. The pathway has gained renewed attention from lawmakers after the FDA approved Biogen Inc.’s Alzheimer’s drug Aduhelm against the recommendation of its scientific advisers.

Accelerated approval drugs can be very expensive—many of them over $10,000 per month—and many more are in the pipeline, according to Matt Salo, executive director of the National Association of Medicaid Directors. The Oregon proposal is a sign that states are worried about how they’ll pay for such treatments, he said.

Other states will be watching the response of the Centers for Medicare & Medicaid Services to the Oregon proposal “very closely,” Salo said.

Annual Medicaid spending on accelerated approval drugs increased from $728 million in 2015 to $1.44 billion in 2020, and the percentage of program spending that went to such drugs increased from 2.3% to 4.2%, according to a 2021 study in Health Affairs.

Confirmatory Trials

Drugmakers ordinarily must show that their products produce a benefit through lengthy and costly clinical trials to win approval—meaning a favorable effect on how a patient feels, functions, or survives.

Accelerated approval removes the requirement to run clinical trials upfront. Instead, drugs are approved based on their effect on a “surrogate endpoint,” an objective indication thought likely to lead to a clinical benefit.

The result has been quicker approval of promising drugs. But Oregon’s proposal zeroes in on a frequent criticism of the accelerated approval pathway: that it removes pressure on drugmakers to run the clinical trials that are needed to show that their products do, in fact, produce a clinical benefit.

The Oregon proposal is part of the state’s application to renew and amend its Section 1115 waiver, referring to special conditions under which it runs its Medicaid program.

Section 1115 is a part of the Social Security Act that deals with Medicaid and allows the secretary of the Department of Health and Human Services to waive program requirements to allow states to test new approaches to coverage and payment.

Oregon’s current waiver is set to expire June 30. The federal comment period on the renewal proposal closed April 7.

Current Medicaid regulations generally require states to cover all drugs that have been approved by the FDA, including where the drugmaker subsequently fails to show clinical efficacy within the timelines that were imposed as a condition of accelerated approval, the Oregon renewal application said.

In return for guaranteed Medicaid coverage for their FDA-approved drugs, drugmakers are required to pay large rebates to the states. Medicaid spent about $64 billion on outpatient prescription drugs in 2017, and collected $34.9 billion in rebates, resulting in net spending of $29.1 billion, according to the Medicaid and CHIP Payment and Access Commission.

Allowing Oregon to exclude accelerated approval drugs would give drugmakers an additional incentive to complete the required clinical trials, and would ensure that states are paying only for drugs that have been proven to provide a clinical benefit, Oregon said.

That is not always the case under the current system, said Rachel Sachs, a professor at the Washington University School of Law.

“There are cases where a drug manufacturer completes the confirmatory trial on a drug that has received accelerated approval, the trial fails, and the drug stays on the market,” Sachs said. “And the FDA either can’t or won’t remove it. And that raises an important question: should the states and the taxpayers have to spend their limited resources on a product that has no demonstrated evidence of clinical benefit?”

Cancer Drugs

But those who look at the issue of accelerated approval drugs from the standpoint of patients rather than of the Medicaid program as a whole ask a different question: whether it makes sense to allow states to restrict access to lifesaving drugs for low-income patients in the name of cost savings.

“This is a matter of incredible importance for cancer patients,” said Mark Fleury, a principal on the policy development team at the American Cancer Society. “Oncology makes up the lion’s share of accelerated approvals for all drug types, and within oncology, the majority of new molecular entities that have been approved over the past three years have been via accelerated approval.”

The impact on drug availability for patients who have no other treatment options have been dramatic, he said. The accelerated approval process has reduced the time for drugs to hit the market by 3.4 years on average.

“For cancer patients, that can make all the difference,” he said. “This process really is working. It really is granting patients earlier access to life-extending and lifesaving treatments.”

Policy Proposals

The problem with the Oregon proposal is that its target is the drug companies but its victims are Medicaid enrollees in need of accelerated approval drugs, said Wayne Turner, a senior attorney in the National Health Law Program.

“This isn’t a problem for the individual states to handle through the Section 1115 waiver program,” Turner said. “This is a matter for Congress.”

A variety of policy proposals have surfaced in Congress aimed at reforming the accelerated approval pathway and pressuring drug companies to complete confirmatory clinical trials.

These include allowing the FDA to take quicker action to remove drugs from the market once they have failed to demonstrate clinical benefit, requiring drugmakers to provide a plan for confirmatory trials before obtaining accelerated approval, increasing reporting requirements related to confirmatory trials, and imposing fines on drugmakers that fail to complete the trials.

A proposal floated by MACPAC would require drugmakers to pay increased rebates for accelerated approval drugs.

But looming in the background is a more fundamental issue for Congress to address, said Salo: how to help state Medicaid programs pay for an expected flood of expensive new treatments in the coming years.

“There’s a whole world of new therapies coming our way, we’ve really made it a national priority to go ‘all in’ on innovation, but we haven’t had the follow on conversation about the cost of innovation, and how we’ll pay for it,” he said.

“You’d find a lot of agreement from the states about this: we’re probably going to need help from our federal partners to spread the cost out more broadly.”

 
 

Clipped from: https://news.bloomberglaw.com/health-law-and-business/new-cancer-drug-access-at-risk-in-oregon-medicaid-proposal

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OK- Proposed Medicaid solution in legislation aims to improve efficiency and outcomes

[MM Curator Summary]: The state is now going with a provider-led entity model to bring managed care back (maybe).

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

Measures to create a system for managing Oklahoma’s Medicaid program in-state authored by Rep. Marcus McEntire, R-Duncan, and Sen. Greg McCortney, R-Ada, are headed for discussion in conference committee. (Photo by Alexandr Podvalny via Unsplash)

OKLAHOMA CITY – After the courts put an end to Gov. Kevin Stitt’s plan to privatize much of the state’s Medicaid program last year, it was left to lawmakers to come up with an alternative solution – one that would improve efficiencies and outcomes while keeping administrative dollars in-state.

Rep. Marcus McEntire, R-Duncan, and Sen. Greg McCortney, R-Ada, are authors on legislation intended to do that. The measures have some additional hurdles to clear before they can be implemented, however, and are sure to be intensely “cussed and discussed,” as McEntire put it, during the last few weeks of the legislative session.

McEntire recently told lawmakers on the floor of the House of Representatives claimed the plan lawmakers are working on could reverse the trend of the last few years and help rural hospitals reopen, or resume providing obstetrics care.

“Every hospital, rural or urban, will be profitable again on their Medicaid clientele since the first time since the ACA (Affordable Care Act) was passed,” McEntire told lawmakers when the bills came before the full House of Representatives on April 28. “And we’re talking real money here, that they’re going to be able to reinvest in their communities.”

The plan gives lawmakers more control to continually tweak the program to address constituent needs, and to ensure that the healthcare companies involved are focused on efficiently spending Medicaid dollars to get the best health outcomes for patients.

After voters approved State Question 802 in 2020, expanding Medicaid, lawmakers set about figuring out a way to pay for it and make sure the program was administered efficiently. Stitt pushed for managed care, having the Oklahoma Health Care Authority award roughly $6 billion in contracts to a handful of national insurance companies.

The Oklahoma Supreme Court struck down that deal, finding OHCA did not have the legislative approval to move forward with the managed care plan, and the expansion approved by voters did not authorize such a program.

Oklahoma last attempted managed care in the 1990s, but amended the plan after seeing a precipitous decline in participating physicians, resulting in scarcity of care.

Oklahoma-based companies would better implement the state’s Medicaid program, and lawmakers should monitor progress to ensure that the funding they receive is concentrated in providing healthcare services rather than boosting profits, McEntire said. The proposed plan would encourage provider-led entities such as Integris to expand their accountable care organizations statewide, and those Oklahoma-based organizations would likely partner with larger, national companies to provide financial backing, he said.

“This plan puts an Oklahoma provider-led entity in the middle of that,” McEntire said. “The money will stop there in state. There is no doubt these provider led entities do not have the financial reserves to take on this much risk; they will need somebody financially backing them…

“If they overshoot those capitated amounts they’re going to need an insurance company behind them with the financial reserves to come in and bail them out because the state is not going to,” McEntire said.

The plan shifts the Medicaid program from a fee-for-service model to a value-based system, providing bonuses for improved outcomes and encouraging providers to take a more holistic approach to care.

Plus, the state would be able to leverage federal dollars to make sweeping change while keeping the cost of the program “net revenue neutral” for the state, McEntire said.

The measures were introduced as amendments on the House floor, introducing a lot of new language late in the legislative process. Though the measures were approved with overwhelming support in the House, the amendments were rejected by the Senate on May 5, sending the bills into discussions in conference committees over the next few weeks.

 
 

Clipped from: https://journalrecord.com/2022/05/09/proposed-medicaid-solution-in-legislation-aims-to-improve-efficiency-and-outcomes/

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Contracted Medicaid Managed Care Providers Treated Few Beneficiaries

[MM Curator Summary]: The PAR rate is even worse than we thought.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

Treatment from contracted Medicaid managed care providers was highly concentrated, with a quarter of physicians and specialists accounting for the majority of claims.

 
 

Source: Getty Images

 
 

By Victoria Bailey

May 04, 2022 – Around one-third of primary care and specialty physicians that contracted with Medicaid managed care plans saw fewer than ten Medicaid beneficiaries over a year, suggesting that network adequacy standards may not accurately reflect beneficiary access to physicians, a Health Affairs study found.

Over 70 percent of Medicaid beneficiaries are enrolled in managed care plans, which are responsible for constructing physician networks from which beneficiaries can seek care. Physician networks in Medicaid managed care plans are typically similar to those in private plans offered through the state health insurance market.

However, network directories may be out of date or list physicians that are not willing to treat Medicaid beneficiaries, indicating that the networks may not reflect the actual availability of physicians. In addition, beneficiaries may prefer providers not included in the network.

To understand how accurate Medicaid managed care plan networks are in determining the availability of physicians for Medicaid beneficiaries, researchers gathered administrative medical claims, Medicaid eligibility and enrollment files, and provider network directories for managed care plans in Kansas, Louisiana, Michigan, and Tennessee between 2015 and 2017.

There were around 22,000 physicians in adult primary care, pediatric primary care, cardiology, and psychiatry in Medicaid managed care networks across the four states, the study found.

About 16 percent of the physicians saw zero Medicaid beneficiaries over one year—defined as ghost physicians. Psychiatrists were the most likely to be ghost physicians, with 35.5 percent treating no Medicaid beneficiaries. Pediatric primary care physicians were least likely to be ghost physicians (11 percent).

Similarly, 17 percent of physicians treated between one and ten Medicaid beneficiaries and were classified as peripheral physicians. Nearly 43 percent of providers saw between 11 and 150 beneficiaries (standard physicians), while 23.7 percent of providers treated more than 150 beneficiaries within a year (core physicians).

The majority of physicians (87.8 percent) who provided care to Medicaid beneficiaries were contracted with Medicaid managed care plans, but 2,500 out-of-network physicians treated at least one Medicaid beneficiary. This suggests that there is a small level of care available to beneficiaries outside the physicians listed in network directories.

Treatment from physicians included in Medicaid managed care plan networks was highly concentrated among small percentages of physicians.

For example, among pediatric and adult primary care physicians that treated at least one Medicaid beneficiary, 25 percent of physicians were responsible for 86.2 percent of claims. Additionally, a quarter of cardiologists accounted for 69.2 percent of claims and 25 percent of psychiatrists were responsible for 86.5 percent of claims.

Among physicians who treated more than 150 Medicaid beneficiaries, 29 percent of primary care physicians accounted for 88 percent of care, 22 percent of cardiologists provided 632 percent of the care, and 15 percent of psychiatrists were responsible for 70.6 percent of care.

Care concentration was slightly higher in urban areas compared to rural areas, the study noted.

Network adequacy requirements vary across the 20 states that have them. Some require plans to contract with at least one primary care provider for every 100 beneficiaries, while others require one provider for every 2,500 beneficiaries.

Based on these network adequacy standards, 94.2 percent of the counties in the four states included in the study had sufficient access to primary care physicians, with an average of one primary care physician for every 440 beneficiaries.

Across the four states, 12.4 percent of counties met the standard for cardiologists, while 10.4 percent met the standard for psychiatrists. After excluding ghost and peripheral physicians, these figures decreased for each provider group.

“Our findings suggest that provider network directories may overstate the availability of physicians in the Medicaid program; many states’ reliance on directories to ensure network adequacy may be insufficient to ensure satisfactory access to physicians who are both valued by Medicaid managed care beneficiaries and willing to treat them,” the researchers wrote.

Medicaid managed care plans are required to demonstrate the adequacy of their networks, but federal leaders have not provided much oversight on how to do this, the study noted. In addition, state network adequacy standards and enforcement vary widely.

Researchers suggested two policy solutions to improve the oversight of Medicaid provider networks. First, states should direct resources to regularly evaluate managed care networks through a combination of audit studies and administrative claims data.

Additionally, states should enact strict penalties for managed care plans that do not comply with network adequacy standards.

 
 

Clipped from: https://healthpayerintelligence.com/news/contracted-medicaid-managed-care-providers-treated-few-beneficiaries
 

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Senior Business Analyst – Medicaid Eligibility Systems Job in Concord, NH at Public Consulting Group

 
 

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Public Consulting GroupConcord, NH

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  • Overview About Public Consulting Group Public Consulting Group, Inc. (PCG) is a leading public sector solutions implementation and operations improvement firm that partners with health, education, and human services agencies to improve lives.
  • Founded in 1986 and headquartered in Boston, Massachusetts, PCG has over 2,500 professionals in more than 60 offices worldwide.
  • PCG’s Technology Consulting practice offers a full spectrum of quality Information Technology (IT) services to help state and local government agencies at every stage of the IT life cycle.
  • Through its specialized IT services, PCG’s Technology Consulting team finds cost-effective ways to help agency partners deliver successful IT systems that enhance the lives of the user base.
  • To learn more, visit Responsibilities Consultant/Analyst will provide a combination of Medicaid and Project Management expertise in monitoring project lifecycle implementations in waterfall, agile and/or hybrid methodologies and providing advisory services on best practices and problem remediation strategies.
  • The incumbent will assess project status progress and quality in accordance with PMI standards as applied in the context of eligibility systems design, development, implementation, and operations.
  • The successful candidate will have either state agency or vendor experience with state Medicaid eligibility systems which includes knowledge of eligibility programs and state options.
  • Experience as an eligibility worker, supervisor, or state eligibility program or operations manager highly preferred.
  • The Consultant will report to the team leader on project status through participation and observation of DDI activities in the requirements, construction, system integration testing, UAT, and go-live phases of DDi activites.
  • Will contribute to deliverables and work products delivered by the by the team.
  • These deliverables and work products will be completed in accordance with our overall strategy, approach, and methodology.
  • Provides project management and technical expertise on large-scale IT projects
  • Supports development of all deliverables, status reports and other work products
  • Supports activities to plan and oversee all project work and develop/manage any potential organizational change management strategies or processes that might be needed
  • Support the goals and outcomes of the project stakeholders
  • Support Developing, managing, and updating Project Plan and other project documents (e.g., Communication Plan, Risk Plan, Stakeholder Register, Resource Plan)
  • Support and or develop, manage, and update the execution of the Project Schedule to ensure project scope and applicable milestones are met
  • Support or develop and deliver regular status reporting
  • Identifies, tracks, and manages project risks; including coordination for risk mitigation
  • Identifies, tracks, and manages project issues; including coordination for issue resolution
  • Establish a response and track the response to project recommendations (e.g., Quality Assurance (QA) vendor recommendations)
  • Provide ongoing communication (e.g., email, meetings) to provide project status
  • Collaborate with the project’s Communication Manager to enhance communication efforts
  • Review project and related operational processes and provide input for improvement by implementing relevant lean or agile strategies
  • Conduct Agile Project Management and Organizational Change Management workshops Qualifications Required: •Direct experience with state Medicaid eligibility systems •State agency work experience with Medicaid, SNAP, TANF or other health and human service programs
  • Self-directed and reports to the Engagement Manager
  • 3+ years of prior project management experience using both Agile and Waterfall techniques in IT related projects to include operations, infrastructure, and application development projects
  • Certified Scrum Master or PMI Agile Certified Practitioner certification
  • QA / IV&V experience preferred
  • PMI Project Management Professional certification #LI-AH1 #D-PCG #LI-remote EEO Statement Public Consulting Group is an Equal Opportunity Employer dedicated to celebrating diversity and intentionally creating a culture of inclusion.
  • We believe that we work best when our employees feel empowered and accepted, and that starts by honoring each of our unique life experiences.
  • At PCG, all aspects of employment regarding recruitment, hiring, training, promotion, compensation, benefits, transfers, layoffs, return from layoff, company-sponsored training, education, and social and recreational programs are based on merit, business needs, job requirements, and individual qualifications.
  • We do not discriminate on the basis of race, color, religion or belief, national, social, or ethnic origin, sex, gender identity and/or expression, age, physical, mental, or sensory disability, sexual orientation, marital, civil union, or domestic partnership status, past or present military service, citizenship status, family medical history or genetic information, family or parental status, or any other status protected under federal, state, or local law.
  • PCG will not tolerate discrimination or harassment based on any of these characteristics.
  • PCG believes in health, equality, and prosperity for everyone so we can succeed in changing the ways the public sector, including health, education, technology and human services industries, work.
  • Connect With Public Consulting Group!
  • Public Consulting Group is an equal opportunity employer.
  • All qualified applicants receive consideration for employment without regard to race, color, religion, gender, national origin, age, sexual orientation, gender identity, protected veteran status, or status as a qualified individual with a disability.
  • VEVRAA Federal Contractor.

 
 

Clipped from: https://jobsearcher.com/j/senior-business-analyst-medicaid-eligibility-systems-at-public-consulting-group-in-concord-nh-bG8p3LE?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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Nurse,Quality of Care Review/DC Medicaid Job Washington District of Columbia

 
 

Position:  Nurse, Quality of Care Review (DC Medicaid)
 

Resp &

Qualifications

PURPOSE:

 

The Quality of Care Nurse will effectively identify, prioritize and respond to high level grievances, complaints and complaint appeals from the member or member’s authorized representative for the Commercial or Medicare Advantage lines of business. The incumbent reviews and interprets the grievance or complaint, medical and dental records, narrative notes, in-patient/office policies and all documentation submitted or collected by the plan pertinent to the issue.

The incumbent will also understand the merits of legal and accreditation actions.

ESSENTIAL FUNCTIONS:

 

  • Reviews all member grievances or complaints and complaint appeals concerning the quality of care provided by facilities or practitioners. Contacts members, providers, or other parties involved, as appropriate, verbally and in writing to obtain additional information regarding the complaint. Reviews medical and dental claims information and records, and member and provider correspondence to conduct patient care investigations and renders an investigative finding.
  • Provides detailed written and/or verbal responses to members, providers, and authorized representatives upon completion of a thorough investigation. Responds to follow up questions or concerns with members, providers, and other parties involved in the investigation, as appropriate.
  • Prepares training materials and serves as the professional resource for all quality of care complaints and quality of care appeal complaints.
  • Conducts or participates in nursing research as appropriate. Completes medical research by defining and interpreting medical language, defining and interpreting medical procedures and medical/hospital office policies.
  • Assists with the preparation of regulatory reports by detailing and summarizing the merits of legal or accreditation actions.

QUALIFICATIONS:

 

Education Level:

Licenses/

Certifications:

 

RN – Registered Nurse – State Licensure And/or Compact State Licensure Practice in MD, DC, VA, WV.

Experience:

5 years Clinical experience in direct health care or health insurance payor setting working with quality reporting, or analytics.

Preferred

Qualifications:

 

  • 3 years’ experience in Quality Initiatives, Medical Review, Utilization Management gement or similar Managed Care organization or hospital preferred.
  • Working knowledge of NCQA standards.
  • Bachelor’s degree in Nursing.
  • Behavioral Health Experience.

Knowledge, Skills and Abilities

(KSAs)

  • Demonstrates excellent written and oral communication skills along with effective presentation skills.

    Able to provide verbal and written feedback for improvement. Must understand the appropriate mode of communication based on the subject matter.
  • Computer proficiency and technical aptitude with the ability to utilize MS Office (Excel, Word and Outlook) and web based technology.
  • Ability to exercise sound judgment in making critical decisions.
  • Skill in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
  • Knowledge of patient rights and laws relative to those rights, such as HIPAA
  • Ability to effectively communicate and provide positive customer service to every internal and external customer
  • Proficient in standard medical practices and insurance benefit structures with the ability to use them in varied situration
  • 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 – Enrollment Service

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  to apply:

Closing Date

Please apply before: 4.16.2022

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 l 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.learn4good.com/jobs/washington/district-of-columbia/healthcare/1188681104/e/

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Behavioral Care Advocate – Idaho Medicaid – Telecommute at UnitedHealth Group

 
 

Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that is improving the lives of millions. Here, innovation is not about another gadget; it is about making health care data available wherever and whenever people need it, safely and reliably. There is no room for error. If you are looking for a better place to use your passion and your desire to drive change, this is the place to be. It’s an opportunity to do your life’s best work.(sm)

You have high standards. So do we. Here at UnitedHealth Group, this includes offering an innovative new standard for care management. It goes beyond counseling services and verified referrals to programs integrated across the entire continuum of care. That means you’ll have an opportunity to make an impact on a huge scale – as part of an incredible team culture that’s defining the future of behavioral health care.

You’ll enjoy the flexibility to telecommute from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

 

  • Oversee outpatient treatment for psychiatric and chemical dependency patients
  • Make patient assessments and determine appropriate levels of care
  • Administer benefits, review treatment plans, and coordinate transitions between various areas of care
  • Review service requests for pre authorizations
  • Obtain information from providers on outpatient requests for treatment

You’ll find the pace fast and the challenges ongoing. We’ll expect you to achieve and document measurable results. You’ll also need to think and act quickly while working with a diverse member population.

You’ll 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:

 

  • Master’s degree in Psychology, Social Work, Counseling or Marriage or Family Counseling; OR Licensed Ph.D.; OR Registered Nurse
  • Professional license in the state of residency
  • 2+ years of experience in behavioral health

Preferred Qualifications:

 

  • Experience working in an environment that required coordinating benefits and utilizing multiple groups and resources for patients
  • Experience working with the Medicaid patient population
  • Outpatient and/or partial hospitalization experience
  • Dual diagnosis experience with mental health and substance abuse
  • Residential/inpatient services experience
  • Microsoft Teams Experience
  • Proficiency with Microsoft Office Suite programs (Word, Outlook, Internet)

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 Optum. Here’s the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world’s large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life’s best work.(sm)

Colorado, Connecticut or Nevada Residents Only: The salary range for Colorado residents is $54,400 to $97,000. The salary range for Connecticut / Nevada residents is $60,000 to $106,700. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

All Telecommuters will be required to adhere to UnitedHealth Group’s 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.themuse.com/jobs/unitedhealthgroup/behavioral-care-advocate-idaho-medicaid-telecommute-f87b29?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic