Author: MM_ADMIN
MEDICAID PROGRAM MANAGER 1–A
Job Description
To administer small and less complex statewide Medicaid program(s). Level of Work:Program Manager. Supervision Received:Broad from a higher-level manager/administrator. Supervision Exercised:May provide functional supervision in accordance with the C…Program Manager, Manager, Program, Administrative
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Louisiana Medicaid Health Plan COO job in New Orleans
Found in: Recruit.net US Premium – 23 hours ago
Job Description
Only candidates that live in or are willing to move to Louisiana will be considered.The Manager of Operations is responsible for leading and managing all hands-on operational aspects and activities of various functional areas within the Plan which may include: Claims, Provider Services, Information Technology, Grievance and Appeals, Member Services, Medical Management and the Medicare and Long Term Care lines of business. Assists the Plan leader in the successful growth and performance of the Plan. The Manager of Operations also interfaces, collaborates and works cooperatively with corporate office functional leaders and centralized business departments.
Required Qualifications
Provides day-to-day leadership and management to a service organization that mirrors the mission and core values of the company. Interfaces with corporate office staff as required.* Responsible for driving the Plan toachieve and surpass performance metrics, profitability, and business goals and objectives.* Responsible for employee compliance with, and measurement and effectiveness of all Business Standards of Practiceincluding Project Management and other processes internal and external. Provides timely, accurate, and complete reports on the operating condition of the Plan. Develops policies and procedures for assigned areas. Ensuring that other impacted areas, as appropriate, review new and changedpolicies.* Assists the Plan leader in collaborative efforts related to the development, communication and implementation of effective growth strategies and processes. May be required to spearhead theimplementation of new programs, services, and preparation of bid and grant proposals.* Collaborates with the Plan management team and others to develop and implement action plans for the operational infrastructure ofsystems, processes, and personnel designed to accommodate the rapid growth objectives of the organization.* Assists in defining marketing andadvertising strategies within State guidelines. Participates in the development and implementation of marketing policies for the Plan, and ensures their compliance with program regulations.* Provides assistance inpreparation and review of budgets and variance reports for assigned areas.* Works cooperatively with Network Development team in the development of the provider network. Acts as “client-care officer” through direct contact with all stakeholders. Serves as a liaison with regulatory and other state administration agencies and communicates activity to CEO and reports back to Plan. * Communicates, Motivates and leads a high performance management team. Attract, recruit, train, develop, coach, and retain staff. Fosters a success-oriented, accountable environment within the Plan.* Ensures that performance evaluations and compensation decisions for employees are not influenced by the financial outcomes of claimsdecisions.* Assures compliance to and consistent application of law, rules and regulations, company policies and procedures for all assigned areas. * Prompt response with a sense of urgency/priority to customer requests.Documented follow through/closure. Assists as assigned or required in performing other duties, assignments and/or responsibilities. Must have a managed care experience.
COVID Requirements
CVS Health requires its Colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, or religious belief that prevents them from being vaccinated.
If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 10 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 45 days of your employment. In some states and roles, you may be required to provide proof of full vaccination before you can begin to actively work. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.
If you are unable to be fully vaccinated due to disability, medical condition, or religious belief, you will be required to apply for a reasonable accommodation within the first 10 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. In some states and roles, you may be required to have an approved reasonable accommodation before you can begin to actively work. If your request for an accommodation is not approved, then your employment may be terminated.
Preferred Qualifications
10+ years work experience that reflects a proven track record of proficiency in the competencies noted.Ability to work collaboratively across many teams, prioritize demands from those team, synthesize information received, and generate meaningfulconclusions.Ability to conceive innovative ideas or solutions to meet clients requirements.Excellent communication and relationship management skills. Express thoughts in an organized and articulate manner. Listen very effectively and build a climate of trust and respect with prospective and existing clients andthe consulting communityAbility to work closely with client service, operations, and investment personnelProven leadership and negotiation skills.Demonstrated leadership with relevant initiatives: Business process, enterprise business project management/consulting, financial strategicplanning and analysis, mergers and acquisitions, strategic planning, risk management.Recent and related managed health care experience.
Education
Bachelor’s degree required; Master’s degree preferred.
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.
Assoc Medicaid Analyst Job in Shrewsbury, MA at University of Massachusetts Medical School
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University of Massachusetts Medical SchoolShrewsbury, MA Full-time
- POSITION SUMMARY:Under the direction of the Manager or designee, the Associate Medicaid Analyst performs complex and varied financial, administrative, and customer service functions in support of department specific projects, which may include RMTS coding or time study projects.
- The Associate Medicaid Analyst is also responsible for School-based Medicaid claiming processes and general operations, which require a high degree of independent action and the setting of priorities and procedures for accomplishing tasks.
- This position will also participate as a member of multiple project teams.
- REQUIRED QUALIFICATIONS:Bachelors degree in Business Administration, Accounting, Finance, or equivalent 1-3 years of relevant experienceDemonstrated ability to review, research, assess and interpret healthcare billing and claiming information Ability to design and program spreadsheets, databases, or custom reportsProficiency with Microsoft Office or similar software, specifically Outlook, Word, Excel, Powerpoint and Access.
- Excellent interpersonal, verbal and writing skills needed to present or communicate effectively with all levels of managementMust possess strong organizational skills, the ability to establish priorities, and resolve problems independentlyAbility to maintain complex records and prepare periodic complex financial reportsDemonstrates investigation skills and initiative, judgment and discretion
- About School Based Claiming (SBC)Federal financial participation (FFP) is available through Title XIX and Title XXI of the Social Security Act to match expenditures by cities and towns, regional school districts and charter schools (collectively, Local Education Agencies (LEAs
- for the provision of medically necessary medical services provided to Medicaid-enrolled students.
- Also eligible for FFP are the LEA costs associated with performing Medicaid administrative activities related to the delivery of services and with performing qualifying outreach activities.
- Collectively, this program is referred to as the School-Based Medicaid Program.
- The SBC unit at HCFS works closely with Massachusetts and other states to develop, implement, and manage various activities that support direct service or administrative activity claiming to the Medicaid program.
- To that end, SBC develops, maintains, and supports solutions for states to compile, report and review eligible expenditures for Medicaid Administrative Claiming, Direct Service Cost Report Reconciliation and Settlement, Medicaid Eligibility Matching, Random Moment Time Studies or other equivalent allocation methods to support the identification of Medicaid related costs.
- With a deep knowledge of federal Medicaid regulations, SBC optimizes opportunities, while ensuring compliance with all applicable state and federal rules.
- Today, SBC supports over 50,000 users in 10 states for school-based other social service agency Medicaid FFP claiming programs.
Business Analyst – Medicaid Systems Product Job in Commerce City, CO at Maximus
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- Since 1975, Maximus has operated under its founding mission of Helping Government Serve the People, enabling citizens around the globe to successfully engage with their governments at all levels and across a variety of health and human services programs.
- Maximus delivers innovative business process management and technology solutions that contribute to improved outcomes for citizens and higher levels of productivity, accuracy, accountability and efficiency of government-sponsored programs.
- With more than 30,000 employees worldwide, Maximus is a proud partner to government agencies in the United States, Australia, Canada, Saudi Arabia, Singapore and the United Kingdom.
- For more information, visit a large employer and Federal contractor, Maximus is subject to various vaccine mandates across our lines of business.
- Maximus is committed to complying with any applicable vaccine mandates.
- The specific vaccine requirements for this position will be outlined throughout the selection process.
- Individuals who believe they may qualify for a medical or religious accommodation will have the opportunity to apply for an accommodation following an offer of employment.
- Essential Duties and Responsibilities: Deliver results after thorough research of functional needs by collaborating and communicating with various stakeholders, both internal and external to the company.
- Apply strong analytical reasoning to understand end user’s requirements and transforms them into operational application.
- Acquire deep knowledge of working systems and bring efficient and effective changes for better performance.
- Participate in the administration of project and program contract activities.
- Extract, analyze, and report data to support program activity and assist in management decision making.
- Audit, evaluate, track, and report program implementation and project activity for Quality Assurance and contract compliance purposes.
- Plan, implement and maintain program and contractual changes.
- Work closely with operations and systems staff to define requirements, test criteria, and success factors.
- Perform other duties as assigned by management.
- Minimum Requirements: Bachelor’s degree with 3 years of experience.
- May have additional training or education in area of specialization.
- Develops solutions to a variety of problems of moderate scope & complexity.
- General application of concepts & principles.
- Contributes to the completion of organizational projects & goals.
- Frequentuse and general knowledge of industry practices, techniques, and standards.
- Applies knowledge and skills to complete a wide range of tasks.
- Communicates on complex or sensitive issues or drafts such responses for supervisor or manager.
- Additional Requirements: 3 years of MMIS experience.
- 3 years operating in an Agile environment.
- Preferred requirements: SAFe certification.
- 3 years of provider enrollment experience.
- 3 years working on product teams.
MARKET DEVELOPMENT ADVISOR MEDICAID PROVIDER SERVICE OPERATIONS in San Antonio Texas
Description
The Market Development Advisor – Medicaid Provider Service Operations provides support to assigned health plan and/or specialty companies relative to Medicaid Group product implementation, operations, contract compliance, and federal contract application submissions. The Market Development Advisor works on problems of diverse scope and complexity ranging from moderate to substantial.
Responsibilities
The Market Development Advisor – Medicaid Provider Service Operations is responsible for driving operational excellence for end to end Provider Service and Experience in the Ohio Department of Medicaid Managed Care Contract. Ensures that assigned health plans are meeting or exceeding corporate Medicaid performance benchmarks. Maintains relationships with internal and external key stakeholder including the Ohio Department of Medicaid. Advises 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 as the provider services Medicaid subject matter expert. Uses independent judgment requiring analysis of variable factors and determining the best course of action. This position works on problems of diverse scope and complexity ranging from moderate to substantial. This is a highly collaborative role requiring critical thinking and problem solving skills, independence, tactical execution on strategy, and attention to detail. This position reports to the Director of Provider Experience and Network Transformation.
Key Responsibilities
- Contributes to the operational success of Humana Healthy Horizons Provider Service and Experience Organization in accordance with the Ohio Department of Medicaid Managed Care contract
- Serve as Lead/Chief of Staff to drive provider relations strategy, process improvement and project management
- Supports Director in the oversight of the Ohio Medicaid’s plan’s provider relations and practice transformation to ensure Perfect Provider Experiences and compliance with all provider services requirements of the ODM Managed Care contract
- Solve complex business challenges and seeks to alleviate provider service disruptions and provider abrasion
- Supports Director in the development and execution of Physician Advisory Councils
- Works collaboratively with key stakeholders across the enterprise and externally with community and business partners including the Ohio Department of Medicaid
- Analyze internal and external data in support of development of policy, process, strategy and improvement
- Monitors performance against key performance indicators, contract requirements and compliance.
Required Qualifications
- Bachelor’s Degree
- 5+ years experience with Medicaid managed care operations, provider relations, network operations, claims knowledge and/or operations, and knowledge of value based provider arrangement and reimbursement methodology
- 3 – 5 years managing mid-large scale projects and cross functional teams
- Proven expertise in driving operational efficiencies and management of processes and procedures. Adept at managing processes from concept to completion ensuring timely on-target, on-budget results
- Ability to analyze data and make informed recommendations
- Demonstrated skills in executing on strategic playbooks or roadmaps in alignment with organizational goals
- Ability to identify, structure and solve complex business problems
- Highly developed computer skills in Microsoft Office applications
- Excellent interpersonal, organizational, written, and oral communication and presentation skills with proven experience developing and delivering presentations to members of the leadership team
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences
- WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10×1 (10mbs download x 1mbs upload) is required.
Preferred Qualifications
- Master’s degree
- Experience responding to state and/or federal government Request of Proposals, Readiness Review and other solicitations
- Experience developing relationships with key stakeholders to understand and improve the market
Additional Information
Position can be Office/Remote/WAH
Occasional travel may be required
For this job, associates are required to be fully COVID vaccinated or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are ahealthcarecompany committed to putting health and safety first for our members, patients, associates, and the communities we serve.
If progressed to offer, you will be required to:
- Provide proof of full vaccinationor commit to testing protocols.OR*
- Provide proof of applicable exemption including any required supporting documentation
Medical, religious, state and remote-only work exemptions are available.
Scheduled Weekly Hours
40
Web Reference : AJF/293842248-202
Posted Date : Thu, 31 Mar 2022
Please note, to apply for this position you will complete an application form on another website provided by or on behalf of Humana. Any external website and application process is not under the control or responsibility of IT JobServe
Medicaid/Medicare Services Specialist II | Commonwealth of Kentucky
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4/10/2022 (8:00 PM EDT)
22-02657
Medicaid/Medicare Services Specialist II
Pay Grade 14
Salary $35,246.40
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
Location Varies
We encourage applicants from all counties to apply as this position is approved for telecommuting.
The agency may authorized the selected candidate to telecommute. The candidate may need to report to Franklin County as needed. The agency may terminate or modify the telecommuting arrangement at any time.
Description
The Cabinet for Health and Family Services ( CHFS) is one of the largest agencies in state government, with nearly 8,000 full and part time employees focused on improving the lives and health of Kentuckians. The Kentucky Department for Medicaid Services provides assistance with medical care for people with limited income and resources. The Division of Policy and Operations is devoted to ensuring beneficiaries receive quality medical care while preventing fraud, abuse and misuse.
The Enrollment Processing Branch processes system updates to ensure Medicaid Members have access to needed services and provides direction and guidance to the call center staff servicing Members and Providers Services . The Branch researches complex situations and provides assistance to Medicaid Members and Providers and other Divisions as needed.
The Medicaid/Medicare Services Specialist II in the Division of Policy and Operations, Enrollment Processing Branch will have the opportunity to work with friendly collogues in a rewarding atmosphere. The Enrollment Processing Branch processes system updates to ensure Medicaid Members have access to needed services and provide direction and guidance to the call center staff servicing our Members and Providers Services. The Branch researches complex situations and provides assistance to Medicaid Members and Providers and other Divisions as needed.
Responsibilities and Job Duties may include but are not limited to:
- Processing advanced complex enrollment functions
- Processing enrollment incidents assigned via CRM and email
- Responds to complicated inquiries from recipients and providers of Medicaid services, coverage and other issues
- Formulate written and oral responses to issues related to enrollment and eligibility
- Provide support and guidance to call center staff
- Ensure enrollment and eligibility updates and changes are managed correctly
- Perform in-depth review, research and analysis of healthcare information
Preferred Skills And Abilities
- Experience using KYMMIS, CRM and Worker Portal
- Excellent computer skills, especially accurately entering information and attention to detail
- Excellent organization and communication skills
- Adaptable attitude
- Excellent customer service skills
- Excellent written and verbal communication skills
Minimum Requirements
EDUCATION: Graduate of a college or university with a bachelor’s degree.
EXPERIENCE, TRAINING, OR SKILLS: Two 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 fields 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 Cindy Toll at Cindy.Toll@ky.gov or 502-564-6890.
An Equal Opportunity Employer M/F/D
Medicaid / Healthcare Quality Assurance Analyst / Etl Tester Job in Latham, NY at CMA
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- Position DescriptionPerform the duties of a Quality Assurance Analyst/ETL Tester to assist with our MDW Project.
- Mandatory Skills 4 years of relevant experience preferably in NY Medicaid/ health care industry 4 years of extensive experience in Data Warehouse ETL testing, at a developer level 4 years of experience in writing complex PL/SQL queries related to healthcare at a developer level 2 years of experience as a Healthcare Business analyst/Front—end testing.
- Complete knowledge of SDLC Strong ability to write ETL test scripts from ETL mapping artifacts Strong ability to execute and do detail data mining, data analysis of Test Results.
- Review functional and design specifications to ensure full understanding of individual deliverables.
- identify test requirements from Design specifications, Map test case requirement and design test coverage plan.
- Develop, document, and maintain functional test cases and test artifacts.
- Execute and evaluate front-end/backend manual or automated test cases and document/report test results.
- hold and facilitate test plan/case reviews with cross functional team members.
- Ensure that validated deliverables meet functional and design specification.
- Isolate, replicate, and report defects and verify defect fixes.
- Knowledge of different Databases such as Oracle, Vertica
- SQL serverPreferred Skills Ability to communicate effectively, provide presentation and walkthrough of test artifacts with Client Ability to work in a very fast paced environment.
- Ability to communicate effectively, provide presentation and walkthrough of test artifacts with Client Ability to work in a very fast paced environment.
- Capable of Multi-tasking Team player – ability to peer review ISTQB or similar testing certification PL/SQL certification
Director State and Local California Medicaid
The KPMG Advisory practice is currently our fastest growing practice. We are seeing tremendous client demand, and looking forward we don’t anticipate that slowing down. In this ever-changing market environment, our professionals must be adaptable and thrive in a collaborative, team-driven culture. At KPMG, our people are our number one priority. With a wealth of learning and career development opportunities, a world-class training facility and leading market tools, we make sure our people continue to grow both professionally and personally. If you’re looking for a firm with a strong team connection where you can be your whole self, have an impact, advance your skills, deepen your experiences, and have the flexibility and access to constantly find new areas of inspiration and expand your capabilities, then consider a career in Advisory.
KPMG is currently seeking a Director State and Local CA Medicaid in Customer & Operations for our Consulting practice.
Responsibilities:
Manage and deliver large, complex public services and state/local government engagements that identify, design and implement creative business and technology services for Medicaid government clients
Develop and execute methodologies and solutions specific to the public sector and state/local government industry coupled with proven experience with Medicaid and MMIS modernization, with preference for prior work with large Medicaid programs in the western United States
Handle engagement risk, project economics, planning and budgeting, account receivables and definition of deliverable content to help to ensure buy-in of proposed solutions from top management levels
Develop and maintain relationships with many senior managements at state/local government agencies, positioning self and the firm for opportunities to generate new business
Evaluate projects from a technical stance, helping to ensure that the development methods used are correct and practical; evaluate risks related to requirements management, business process definition, testing processes, internal controls, project communications, training and organizational change management
Manage the day-to-day interactions with client managers
Qualifications:
Minimum ten years of recent experience in the Health and Human Services Medicaid solution delivery market, working for a commercial off-the-shelf (COTS) solution provider or consulting organization with a minimum of eight years of experience managing large, complex technology projects on the scale of a State Medicaid Maintenance Management Information System (MMIS) solution along with proven experience with Medicaid and MMIS modernization
Bachelor’s degree of technical sciences or information systems from an accredited university or college
Prior experience and has served in a team supervisory role on at least one MMIS implementation and one MMIS M&O engagement such as Program Manager, Module Project Manager, Solution Architect, Technical Solution Lead, or Quality/Testing Manager
Demonstrated experience leading teams of more than twenty staff, including staff from diverse organizations to successfully implement and operate technology-based solutions; experience and relationships with states in the western United States preferred
Hands-on experience with the Center for Medicare and Medicaid Services (CMS) Medicaid Information Technology Architecture (MITA), Medicaid Certification Lifecycle, associated toolkit and CMS checklists
Capable of presenting Medicaid topics to large, varied audiences in either written or verbal presentation format and experience in working on customer proposals or deal capture teams in the State Medicaid market
Travel may be up to 80-100%
Applicants must be currently authorized to work in the United States without the need for visa sponsorship now or in the future
KPMG LLP (the U.S. member firm of KPMG International) offers a comprehensive compensation and benefits package. KPMG is an affirmative action-equal opportunity employer. KPMG complies with all applicable federal, state and local laws regarding recruitment and hiring. All qualified applicants are considered for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other category protected by applicable federal, state or local laws. The attached link contains further information regarding the firm’s compliance with federal, state and local recruitment and hiring laws. No phone calls or agencies please.
At KPMG, any partner or employee must be fully vaccinated or test negative for COVID-19 in order to go to any KPMG office, client site or KPMG event. In some circumstances, individuals who are not fully vaccinated may also be required to have a reasonable accommodation to not be fully vaccinated for COVID-19.
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Senior Director, Medicaid Market, Mid-Atlantic – Rockville MD – March-30-2022
Description:
The Market Medicaid Leader is the voice of Medicaid internally andexternally.
Reporting to the Senior Vice President, National Medicaid and the MAS VPof MSBD, the Market Medicaid line of business leader is responsible for the overall performance of the market Medicaid line of business program, with 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 market [Permanente] and Administration. 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 market and National Executive Sponsorship on strategic issues/development, business performance, and progress against objectives. Demonstrated passion and creativity in developing models of care serving low income vulnerable populations.
Essential Responsibilities:
- Position the market as the leader for quality, care delivery for high need vulnerable populations. The position is responsible for customer experience, achieving membership growth targets, overseeing the Medicaid product portfolio (TANF, ABD, LTSS and Adult Expansion), 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 medical group and health plan delivery system operations and quality.
- Demonstrated strategic thinking with ability to balance long-term direction with need for immediate impact and results. Maintain awareness of the competitive landscape and market trends. Develop capacity to identify new business opportunities for the market to expand its Medicaid footprint. Recognize industry trends and Identify initiatives for market to demonstrate innovation, which could take the form of creative partnerships, marketing, member retention, care delivery or delivery system improvements, or participation in innovative projects managed by the federal government, community or provider partners.
- Ensure market Medicaid plans adhere to national guidance and are aligned with market business strategies, goals and initiatives and lead development of annual market Medicaid membership targets with market forecasting lead. Participate in market forums to ensure alignment of Medicaid strategies with market business plans and assure full integration of Medicaid where applicable; participate in other market forums and serve as the market voice of Medicaid. Serve as principal contact within the region for Medicaid and interface regularly with market executives (MSBD, CFO, HManage the relationship and activities with functional areas as business, regulatory, operations, legal and IT.
- Market Medicaid Operations
- Manage the relationship and activities with functional areas as business, regulatory, operations, legal and IT. Oversee and coordinate the validation and submission of state required reports and work in collaboration with NMER for timely, accurate and complete submission of encounter data. Coordinate resources so that they leverage/align with other initiatives through the organization. In conjunction with National Medicaid implement market geographic and product line Medicaid expansions. Set key performance metrics and ensure that the Medicaid line of business is well-served and drive continuous improvement initiatives related to Medicaid.
- Stakeholder Outreach
- Represent KP with state regulators, departments and representatives as well as local health departments and community-based organizations. Proactively anticipate and respond to state and federal initiatives which impact Medicaid. Manage contractual arrangements with the states, local Departments of Health, and providers including, but not limited to, transportation providers, School Based Health Centers, Federally Qualified Health Centers and CSBs.
- Medicaid compliance and regulatory
- Maintain a deep understanding of state and CMS Medicaid regulations, collaborate with National Medicaid Compliance to ensure all market functions are aware of and compliant with state and CMS Medicaid requirements. Identify market compliance risks and escalate issues as necessary to market and national Medicaid compliance and line of business leaders. Lead State Medicaid audits. Accountable for market remediation of compliance risks with market functional leaders, as needed.
- Financial Accountability, State Medicaid Capitation and Rate Development
- Accountable for the market Medicaid line of business P&L and department budget. Coordinate the market development of rate development templates for annual capitation rates. In conjunction with Actuarial services and Finance represent the market in capitation rate negotiations. Identify revenue and expense opportunities for increased state reimbursement and internal, fiscal improvement opportunities.
- Lead and develop market Medicaid LOB staff
- Ensure market line of business structure is designed to achieve desired outcomes based upon best practices. Hire, onboard, develop and coach market Medicaid staff to sustain a strong and diverse talented team and advance Medicaid performance. Provide opportunities for market staff to learn about the national Medicaid line of business and functional areas to contribute to building their expertise and expand their view of the business line. Ensure leadership succession plans are in place so that key positions can be backfilled with appropriate talent.
Basic Qualifications:
Experience
- Minimum ten (10) years of relevant experience in a Medicaid managed care organization.
- Minimum seven (7) years of management experience.
- Minimum five (5) years in product line management to special populations.
Education
- Bachelors degree or four (4) years relevant experience.
- High School Diploma or General Education Development (GED) required.
License, Certification, Registration
- N/A
Additional Requirements:
- Strong background working with Medicaid and/or Special Populations and unique health care needs.
- 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.
- Knowledgeable of Medicaid health care delivery systems
- Knowledgeable of current trends in care management an industry related to care delivery to Medicaid population.
- Demonstrated ability to build effective partnerships and influence others who may have different perspectives.
- Must be a decisive, results-oriented manager or people. Must excel in developing a highly focused, cohesive team of professionals who are comfortable working in a team environment.
- Demonstrated ability to work in a highly matrixed environment.
- Strong collaborative and team skills.
Preferred Qualifications:
- Twelve (12) years of relevant experience in a Medicaid managed care organization preferred.