Author: MM_ADMIN

 
 

CURRENT SPECTRUM HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Spectrum Health team members only.


Job Summary


Job Description


Provide leadership and direction to the Medicaid Claim Processing teams to ensure that the goals and standards of the department and Priority Health are being met. Facilitate the development of the team within the Claims department. Participate in ongoing development of new products and technologies.
DIRECTION EXERCISED: Manage the Medicaid Claims Team Leaders.


Directly supervises above mentioned employees in accordance with Priority Health’s policies and applicable Federal and State Laws. Responsibilities include but are not limited to effectively interviewing, hiring and training employees; planning, assigning and directing work; appraising performance; rewarding and counseling employees; addressing complaints and resolving problems.


Essential Functions

• CAREER DEVELOPMENT OF STAFF:
  
  
• Ensure that all team members are treated with respect and fairness
• Facilitate the development of the Medicaid team within the Claim Services department.
• Serve as coach, facilitator and motivator to the teams, removing operational roadblocks that result in teams not achieving the operational objectives.
• Ensure that individual team meetings are routinely scheduled to discuss performance results, operational issues, and provide all team members the opportunity to explore alternative approaches to exceed the current performance levels.
• Identify training requirements for individual team members and overall training needs for the entire team to further develop the performance of the teams within the Claims teams.
• Coordinate with the Learning and Development Team all necessary refresher training and new product training required.
• Provide opportunities for and encourage professional growth of individual team members.
• Work with team to set goals.
• Effectively educate team on an ongoing basis relative to day to day changes, company initiatives and communications (internal or external) that may directly effect their interpretations of policy changes or benefit clarification to members, participants, providers, employers and the Priority Health staff.
• MONITORING TEAM PRODUCTION AND QUALITY
  
  
• Develop and implement performance tracking and trending tools to allow for daily monitoring of the team’s performance level for all functions to ensure that departmental standards are met.
• Review the performance of assigned team members on at least a quarterly basis. Identify successes and areas of improvement. Implement appropriate counseling and performance improvement action plans according to Human Resource regulations and guidelines. Termination of employment, when necessary, would be coordinated with Human Resources and Manager’s direct report.
• Ensure consistency exists with the application of operational policies and procedures within the various teams.
• Ensure all benefit language, policies and procedures are interpreted accurately within the teams.
• Monitor team operational and financial performance and initiate corrective actions when required.
• PROCESSING AND PRODUCTION:
  
  
• Auditing and reporting of claims.
• Investigation and resolution of inter/intradepartmental inquiries regarding claims status, benefit issues and adjudication errors.
• PROJECT MANAGEMENT:
  
  
• Participate in Process Improvement Planning (PIP)
• Effectively develop, prioritize and implement project plans as assigned by management.
• Communicate project progress in a clear and timely manner.
• SERVICE TO CUSTOMERS:
  
  
• Represent department in various meetings and committees
• Implement activities to meet customer requirements based on internal feedback and customer survey results.
• OTHER ESSENTIAL FUNCTIONS
  
  
• Monitor any delays or issues with cycle times and develop corrective action plans. Ensure trend reporting is developed and distributed to key personnel.
• Maintain knowledge of operational functions and software.
• Maintain general knowledge of other functional areas of the system and Priority Health business to better assess the impacts of the Operational functions.
• Facilitate continuing improvement of business processes in Claims.
• Provide technical analysis and recommendations as requested by management or staff regarding a variety of issues or problems.
• Identify ways to re-engineer the operational procedures to gain efficiency in operational processes.
• Exercise fiscal responsibility in managing team budgets.
• Participate in ongoing development of new products and technologies. Ensure that Claim Services can administer new and existing products effectively and efficiently.
• Assist in handling members with potential grievances in an effort to achieve an acceptable outcome.
• Create, develop, and design any forms or spreadsheets needed within the department to use for collecting and/or reporting data.
• Other duties as deemed appropriate by Sr. Manager of Claims and/or Chief Operating Officer (COO) of Enterprise Operations.
• Represent department in audit related activities at group, state and/or federal levels to ensure compliance requirements are maintained.
  
  
   

Qualifications

• Required Bachelor’s Degree

 
 

• 3 years of experience typically gained through skills/knowledge/abilities managed care experience and/or training; or equivalent combination of education and experience Required
• 3 years of experience typically gained through skills/knowledge/abilities management experience in a managed care or health care environment Required
• Excellent working knowledge of managed care concepts and HMO operations Required
• Government programs operational experience Preferred
• Knowledge or experience related to TQM, Process Improvement or Reengineering Methodologies
  
  
   

Primary Location

SITE – Priority Health – 1239 E Beltline – Grand Rapids

Department Name

PH – Claims Administration

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

40

Hours of Work

8 a.m. to 5 p.m.

Days Worked

Monday to Friday

Weekend Frequency

Variable weekends
Accommodation Notice: If you are a qualified individual with a disability, you may request a reasonable accommodation in Spectrum Health’s application process. Contact us at 616-486-SHHR (7447).


Spectrum Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, sexual orientation, veteran status, or any other legally protected


category. See more here .

 
 

Clipped from: https://www.linkedin.com/jobs/view/2637882854/

 
 

Description

This position is responsible for assigned Medicaid and SNP product portfolio development and management. The Director will design, implement, maintain, document and analyze current Medicaid and SNP plans, as well as identify, prioritize and develop strategy for product expansion to continuously improve Medica’s Medicaid and SNP market position while working to align products and program offerings with state procurement cycles.

This role will work closely with Medicaid and SNP segment leadership, actuarial, network, sales, operations, marketing, and physician & health services to develop and communicate product intent, and ensure accurate and complete understanding and administration both internally, in the marketplace and with state and federal regulators.

Incumbent must have a proven track record with Medicaid and SNP products and understand the operational, clinical and financial implications of plan designs. Director is subject matter expert on Medicaid and SNP plan performance including membership, income, and operating margin. Position will also implement and manage strategic partnerships, alternative payment arrangements and external vendors.

Qualifications:

• Bachelor’s degree or equivalent combination of education and experience required
• 10+ years Medicaid, Medicare or SNP experience with a track record of successfully leading growth initiatives
• 5+ years leadership experience required
• Medicaid and SNP Products plan benefit design, bid development and operational implementation

Specific types of experience or skills required:

• Product performance monitoring, establishing metrics to measure product success
• CMS and DHS compliance and understanding of MCO regulatory environment
• Health plan operations understanding
• Analytical ability in business planning and financial management
• Demonstrated leadership and influencing skills with the ability to lead and drive change
• Strong communication and presentation skills
• Strong strategic planning skills
• Financial performance measurement skills, accountable for results
• Ability to articulate vision and strategy
• Passionate about member experience and recognized as a positive change agent who can work effectively in creating direction and influence to effective results
• Team player with strong relationship building skills at all levels of the organization and externally
• Creative problem solving skills using innovative approaches
• Ability to handle multiple complex projects with a high degree of engagement
• Strong drive for results and accountability
• Expertise in project development and implementation management

 
 

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

 

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)

Equal Opportunity Employer including Veterans and Disabled Individuals

Clipped from: https://www.minnesotajobnetwork.com/job/detail/57068216/Director-Medicaid-and-SNP-Product-Strategy?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Key Role:

Serve as a healthcare consultant focused on supporting our government client. Support business development and federal client delivery in the evaluation space. Lead capture efforts for the design and execution of formative and outcomes evaluations for client programs, including Center for Medicare & Medicaid Innovation (CMMI) models. Manage across teams and client delivery for evaluation projects.

This position is open to remote delivery anywhere within the U.S., to include the District of Columbia.

Basic Qualifications:

• 7+ years of experience with program evaluation design, implementation, and management
• Experience with developing data collection tools and templates
• Experience with the federal procurement process, including business development and proposal development leadership
• Experience with client management
• Experience with developing evaluation reports and peer-reviewed publications
• Ability to manage a mid-sized team and manage budgets
• MA or MS degree

Additional Qualifications:

• Experience with CMMI Alternative Payment Models
• Experience with payment calculations
• Experience with oncology / radiation oncology programs
• Ph.D.

We’re an EOE that empowers our people—no matter their race, color, religion, sex, gender identity, sexual orientation, national origin, disability, veteran status, or other protected characteristic—to fearlessly drive change.

Clipped from: https://www.glassdoor.com/job-listing/medicare-and-medicaid-program-evaluator-booz-allen-hamilton-JV_IC1153546_KO0,39_KE40,59.htm?jl=4084315776&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Welcome to the Latest Job Vacancies Site 2021 and at this time we would like to inform you of the Latest Job Vacancies from the US Centers For Medicare & Medicaid Services with the position of Supervisory Health Insurance Specialist – US Centers For Medicare & Medicaid Services which was opened this.

If this job matches your qualifications, please send your application directly through our latest Job site. Indeed, every job is not easy to apply because it must meet several qualifications and requirements that we must meet in accordance with the standard criteria of the Company who are looking for potential candidates to work. Good job information Supervisory Health Insurance Specialist – US Centers For Medicare & Medicaid Services Woodlawn below matches your qualifications. Good Luck: D

Collaborating with state or national stakeholders to assess and to address technical needs to ensure successful Medicaid and CHIP enrollment…

• Company Name : US Centers For Medicare & Medicaid Services
• Open Position : Supervisory Health Insurance Specialist – US Centers For Medicare & Medicaid Services Woodlawn
• Location Job : Woodlawn, MD
• Country Job : US

How to Submit an Application:

After reading and knowing the criteria and minimum requirements for qualifications that have been explained from the Supervisory Health Insurance Specialist – US Centers For Medicare & Medicaid Services job info – US Centers For Medicare & Medicaid Services Woodlawn, MD above, thus jobseekers who feel they have not met the requirements including education, age, etc. and really feel interested in the latest job vacancies Supervisory Health Insurance Specialist – US Centers For Medicare & Medicaid Services job info – US Centers For Medicare & Medicaid Services Woodlawn, MD in 05-06-2021 above, should as soon as possible complete and compile a job application file such as a job application letter, CV or curriculum vitae, FC diploma and transcripts and other supplements as described above, in order to register and take part in the admission selection for new employees in the company referred to, sent via the Next Page link below.

US Centers For Medicare & Medicaid Services | Woodlawn, MD Woodlawn, MD MD US 07-07-2021

 
 

Clipped from: https://idblogo.com/job/e4215f1619ac442b/supervisory-health-insurance-specialist-us-centers-for-medicare-medicaid-services.html?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

 
 

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation’s leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.

The AE II is responsible for building, nurturing and maintaining positive working relationships between Plan and its contracted providers. Assigned provider accounts may include single or multiple practices in single or multiple locations, integrated delivery systems or other provider organizations. AE II maintains in depth understanding of Plan’s contracts and provider performance and needs, identifying, developing and conducting relevant and tailored provider orientation sessions, making educational visits and working to resolve provider issues. Responsible for monitoring and managing provider network by assuring appropriate access to services throughout the Plan’s territory in keeping w/ State and Federal contact mandates for all products. Identifies, contacts and actively solicits qualified providers to participate in Plan at new and existing service areas and products, assuring financial integrity of the Plan is maintained and contract management requirements are adhered to, including language, terms and reimbursement requirements. Maintains complete understanding of Plan reports and metrics and uses them to evaluate the performance of assigned providers/practices/facilities, determining, communicating and implementing plans for providers to improve performance and measuring ongoing performance. Uses data to develop and implement methods to improve relationship. Assists in corrective actions required up to and including termination, following Plan policies and procedures. Supports the Quality Management department with the credentialing and re-credentialing processes, investigation of member complains and any potential quality issues. Maintains a functional working knowledge of Facets, including the provider database and routinely relays information about additions, deletions or corrections to the Provider Maintenance Department. Maintains and delivers accurate, timely activity and metric reports as required. Identifies and maintains strong partnerships with appropriate internal resources and stakeholders.

 
 

Education/ Experience:

• Bachelor’s Degree.
• 1 to 3 years previous Account Executive experinces in the manage care space.
• Required Medicaid experience along with 3 to 5 years experience in a Provider Services position working with providers
• 5 ot 10 years experience in the managed care/health insurance industry with demonstrated strengths in:

 
 

• Plan policies and procedures related to provider contracting, provider credentialing, provider billing and payment, provider incentive programs.
• State and Federal regulatory requirements related to providers, claim adjudication systems, provider file database requirements and relevant software applications.
• Substantive Account Executive experience with high impact, high dollar, extremely visible and critical provider groups.
• Working independently and managing complex projects and programs both as an independent owner and team leader, training and mentoring skills, interacting at an executive level internally and externally.

 
 

Note: Presently all of our AmeriHealth Caritas Family of Companies associates are working remotely due to the Pandemic. This role/department will be transitioning to the District of Columbia site when it is safe to return to the office.

Clipped from: https://www.glassdoor.com/job-listing/provider-network-account-executive-ii-medicaid-amerihealth-caritas-JV_IC1138213_KO0,46_KE47,66.htm?jl=4108001985&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Who we are

Since 1981, Families USA Foundation has been a leading national voice for health care consumers. Through our long-standing relationships of consumer leaders, advocates, and partner organizations across all 50 states and the District of Columbia, we have remained steadfast in our mission – Dedicated to the achievement of high-quality, affordable healthcare and improved health for all. We advance our mission through public policy analysis, advocacy, and collaboration with partners to promote a patient-and community-centered health system.

Your Role

We are looking for a Director of Medicaid Initiatives providing strategic leadership and support for Families USA’s Medicaid policy and advocacy projects. Central job responsibilities include providing expert Medicaid policy analysis and strategy and developing Medicaid policy recommendations for the organization related to the Health Policy team’s areas of focus and projects. Collaborate with other departments to develop and implement strategies and tactics to advance Medicaid policy recommendations in these areas, including development efforts. This person will work in close collaboration with the senior leadership team and will also serve as a spokesperson for the organization around Medicaid work.

Main job responsibilities:

• Direct and develop effective organizational strategies related to Medicaid.
• Conduct or direct the completion of activities necessary to execute Medicaid related strategies, including anticipating next steps from Congress or target states.
• Respond to changing political dynamics and maintain focus on the Medicaid program and the organization’s efforts to sustain a strong Medicaid program at the federal and state levels.
• Evaluate the likely impact of changes on Medicaid enrollees’ health care access and assess the organization’s position and appropriate response.
• Stay abreast of, track, and analyze Medicaid related news reports, scholarly studies, articles, and state and federal program changes, legislation, bills, and regulations.
• Collaborate with Strategic Partnerships, Federal Relations, and Communications teams on a broad range of written products and research, including proposals, blogs, research studies, issue briefs, and regulatory comments to implement organizational strategy.
• Establish thought leadership in broader health policy community.
• Maintain positive relationships with funders and external stakeholders and confer with internal and external colleagues about events to refine our position and determine our best response.
• Represent Families USA at external meetings and conferences.
• Serve as a reviewer of draft documents and ensure that written products are of high quality before reaching the Senior Director and Executive Review process.
• Supervise staff including assigning and supervising work, providing feedback, helping staff set long-term goals and monitoring progress, facilitating weekly check-ins, providing opportunities for enrichment through external opportunities and internal meeting participation, and providing mentorship and professional development.

Your Experience

Undergraduate degree in public health, public policy or related field. 5 to 10 years’ experience with high-level content knowledge, knowledge of and experience with federal and state-level policy-making processes (both legislative and administrative). Demonstrated understanding of public programs and the health system, with a focus on Medicaid. Experience representing an organization with media, federal and state regulators, state and national partners, funders, including ability to speak in public. Capacity to handle multiple competing priorities – including developing and executing project plans. Highly motivated team player who contributes to an atmosphere in which people collaborate enthusiastically and effectively to produce results.

Our Workplace

We offer a dynamic, empowering, and collaborative work environment that allows staff to reach their full potential. We offer an extremely attractive total compensation package, including competitive salary, medical, dental, vision, disability and life, 403(b), 3+ weeks’ vacation, nine (9) Federal holidays and our offices are closed between Christmas Eve and New Year’s Day and many more exciting benefit programs.

 
 

Clipped from: https://www.politicaljobhunt.com/jobs/71335667-director-medicaid-initiatives-at-families-usa-foundation?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Description:

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.

Pharmacist Program Manager

*Open to other locations however, the individual is preferred to live in an Eastern Time Zone area. 

The Pharmacist Program Manager is responsible for serving as the primary contact for the BCBS WNY Medicaid pharmacy program.

Primary duties include but are not limited to:

• Represent BCBS WNY Medicaid pharmacy program for the region, externally;

 
 

• Face of plan to Government Relations, NYS DOH
• Attend state meetings, respond to email inquiries

• Represent BCBS WNY Medicaid pharmacy program within the health plan and with PBM vendor
• Maintain, enhance and modify components of the pharmacy program as needed to align with health plan goals and pharmacy program national Medicaid best practice 
• Prepare and present routine pharmacy program updates within various forums, including but not limited to: quarterly business reviews, regulatory meetings, quality meetings to support accreditation, biweekly trend meetings
• On occasion solve claims issues and complaints with the support of Pharmacy Operations team or Medicaid Account Management team
• Perform routine benefit surveillance to assure benefits are working correcting, optimal penetration of preferred products, low claim reject volumes
• Assure successful implementation of program changes including: state mandates and programs to improve the member and provider experience, contain costs and improve quality of service
• Present and report on Enterprise quality programs that impact the market

 
 

• Advocate for plan needs
• Identify, develop, and/or advocate for quality programs that will drive more favorable withhold measures (local, enterprise)
• Report on the productivity and outcomes of clinical quality programs

• Assure appropriate access for health plan staff to RX tools
• Assure all necessary client/vendor accountability reporting is complete, accurate an on time.
• Develop and implement communications to pharmacies, prescribers and members as necessary to improve member and provider experience and reduce cost

Qualifications

Qualifications 

• Requires a registered pharmacist; 2 years of managed care pharmacy experience including knowledge of current health care and managed care pharmacy practices; or any combination of education and experience, which would provide an equivalent background. 
• Current state license to practice pharmacy as a RPH required. 
• Minimum 2 years of managed care pharmacy experience that is NOT RETAIL PHARMACY related preferred
• Proficiency in MS Excel, Power Point, Outlook
• Program Management experience in managed care or other related field
• Must demonstrate proficiency as a key participant in program development, where the program seeks to satisfy regulatory requirements, improve clinical outcomes, quality, cost or other measure.
• Must demonstrate proficiency in clinical/technical communication to business leaders, an ability to communicate messages pertaining to programs and systems using data and other details in a way business leaders can understand
• Professional designation preferred
• Day travel and occasional overnight travel may be required
• Experience with government programs (Medicare/Medicaid) strongly preferred

 
 

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.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

 
 

Clipped from: https://anthemcareers.ttcportals.com/jobs/6985076-pharmacist-program-manager-slash-wny-medicaid-plan?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

About AbbVie


AbbVie’s mission is to discover and deliver innovative medicines that solve serious health issues today and address the medical challenges of tomorrow. We strive to have a remarkable impact on people’s lives across several key therapeutic areas: immunology, oncology, neuroscience, eye care, virology, women’s health and gastroenterology, in addition to products and services across its Allergan Aesthetics portfolio. For more information about AbbVie, please visit us at www.abbvie.com. Follow @abbvie on Twitter, Facebook, Instagram, YouTube and LinkedIn.


Primary Job Function


The US federal and state governments are significant customers of AbbVie ensuring patients covered under their numerous healthcare programs have access to our medicines. Medicaid is one of the largest of these programs. AbbVie contributes to the success of this program by providing discounted prices on our products. The incumbent will manage the analysis, payments, and disputes of a large volume of quarterly rebate claims within required timelines.


Core Job Responsibilities

• Manage and develop three or more direct reports in the payment of rebate claims.
• Offer guidance on the analysis of payments for reasonableness as well as on dispute guidelines.
• Act as a liaison between AbbVie and government customers to drive the team to the settlement of disputes.
• Perform ad hoc legal, management, and customer requests.
• Maintain procedural documentation as required by changes in legislation and business practices.
• Assist various projects related to government system upgrades and/or enhancements.
• Perform other duties as assigned.

 
 

Position Accountability And Scope

Ability to manage a team and perform duties independently or with a low level of supervision. The incumbent is responsible for the accurate and timely payment of Medicaid rebates totaling $3 billion annually to state Medicaid agencies, including providing adequate review and approval of payments as they are processed by team members. Must have the aptitude to understand and analyze payment trends and ensure team members have accurately depicted and explained payment variances from prior periods, including managing and forecasting the right level of balance sheet reserves. Must support corporate cash flow management activities by ensuring payment releases as close to the due date as possible and provide Corporate Treasury weekly payment forecasts during heavy processing periods. Incumbent will ensure team members are current with resolving invoice disputes to keep balances within reasonable levels, including ensuring periodic payment reconciliations with the states as required. Must build strong product knowledge in order to perform the necessary units per script and reimbursement test validations to ensure payment accuracy for key products. Must have a strong technical background to support the various Excel reports and tools required to manage the business, including quickly learning the Medicaid modules in the Model N Revenue Management System. A background in SQL/VBA programming is preferred. Must have the ability to manage multiple priorities, ad-hoc projects, and react to a rapidly changing dynamic work environment. He/she is expected to identify opportunities for productivity and process improvements.

Minimum Education

Qualifications

BA/BS required;

5+ years business experience, preferably with a concentration in contracting, Medicaid related activities or financial analysis

Minimum Experience/Training Required

Incumbent must have the ability to manage a productive team tasked with demands that require responding to a high volume of work that requires absolute accuracy and rapid turnaround time. Must have excellent oral and written communication skills as job responsibilities include communicating with various levels of management within AbbVie as well as with external customers. The job can be demanding at times due to the dynamic nature of the rebate function and the evolving legislative and legal environment. Therefore, it requires ability to respond to change and to continually reprioritize to satisfy demands of a rapidly changing environment. Problem solving and integrity are key competencies of this position. Must be able to drive the process and ensure sound judgment in determining appropriate payments. Extremely strong organizational skills along with a high degree of follow through are requirements. Must have intermediate or higher-level skills with the Microsoft Office Suite, especially Excel. Previous experience with Revenue Management software (i.e., Model N, Revitas, etc.) and SQL/VBA is helpful.

Significant Work Activities
Continuous sitting for prolonged periods (more than 2 consecutive hours in an 8 hour day)
Travel
Yes, 5 % of the Time
Job Type
Experienced
Schedule
Full-time
Job Level Code
M

Clipped from: https://www.linkedin.com/jobs/view/manager-medicaid-claims-at-abbvie-2638105148/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Today

We’re also tackling the social determinants of health by creating non-clinical partnerships in the communities where we work and live, because everyone should have access to quality health care. We use innovative tools and approaches to help members get the most out of their plan benefits, as affordably as possible. We are more than a health care insurer and we are truly anchored in our purpose: to do everything in our power to stand by our members in sickness and in health.

BASIC FUNCTION: This position is responsible for assigned aspects of medical policies and programs. Performs medical reviews and interacts with the provider communities for assigned areas.

ESSENTIAL FUNCTIONS:

• Complete medical necessity prepayment, pre-certification and other claim reviews as required by applicable State and Federal regulations, statute or accreditation requirements.
• Complete peer to peer conversations regarding member plan of care as required by applicable State and Federal regulations, statute, or accreditation requirements.
• Assist in the ongoing activities of utilization review, care/case management, and cost containment programs for assigned lines of business to ensure the consistency and cost effectiveness of review procedures.
• Maintain effective liaison with the other areas of Health Care Management to ensure cooperation with quality and utilization initiatives.
• Devise plans for outcome studies and provides direction to participants.
• Work effectively with appropriate company areas in enhancing HCSC compliance with all application regulations and industry standards such as HIPPA, HEDIS, etc.
• Devise and review statistical reports relating to patterns of care on hospital utilization and practice patterns of physicians. Determine recommendations for follow-up procedures.
• Provide physician clinical expertise to other corporate areas.
• Develop external relationship and liaison with physicians, organized hospital administrators and medical service companies that will enhance the corporate image and serve as a means for providing education and resolving utilization review issues. Represent the corporation at various state and national medical association meetings as required.
• Provide educational assistance to medical providers in the effective control of expenditures of health care dollars through effective utilization review and cost containment while improving the quality of health care.
• Keep appropriate supervisory Medical Management informed of pertinent developments and perform special assignments as required. Assist in the development, implementation and administration of corporate medical policies.
• Must be located in a state or territory of the United States when conducting medical necessity review or peer to peer conversation for the purpose of Utilization management.
• Communicate and interact effectively and professionally with co-workers, management, customers, etc.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
• Maintain complete confidentiality of company business.
• Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

JOB REQUIREMENTS:

• Physician with a current and unrestricted physician license in a state or territory of the United States.
• Maintain Board Certification as a M.D. or D.O. (by a specialty board approved by the American Board of Medical Specialties (doctors of medicine); or the Advisory Board of Osteopathic Specialists (doctors of osteopathic medicine)
• 5 years of clinical experience
• Analytical and communication skills
• Strategic thinking skills

PREFERRED REQUIREMENTS:

* 3 years Managed Care experience highly preferred

 
 

Clipped from: https://www.theladders.com/job/medicaid-medical-director-hcsc-richardson-tx_47203852?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Role: Tableau Specialist – Senior – High (652657)

Duration: 12 Months+

Location: 820 S. Boylan Street, Raleigh, NC 27603

Interview Mode: Either Webcam Interview or In Person

Type: Contract

Start Date: Immediate

NC Medicaid is seeking a Senior Tableau Specialist in combination with strong Cognos experience to support interactive reporting and dashboard creation related to program oversight, quality evaluation, and analysis.

The desired candidate for Senior Tableau Specialist within NC Medicaid will have extensive experience as a Tableau developer in combination with Cognos dashboard and report development, collaboration with and presentation to the business, and solution adoption. Candidate must have the following skill set and experience:

• Expert-level technical/functional development skills in Tableau and Cognos and

o Strong technical skills with database analysis and query tools, such as SQL, SAS, or Business Objects

• Data aggregation, visualization, and reporting experience using Medicaid Management Information systems (MMIS), Medicaid or Commercial Health Care administrative claims, provider and eligibility data, or other large and complex Health Care data sources
• Advanced skills in connecting to various data sources and types, extracting and preparing data, and developing well-designed and effective dashboards and advanced drill down reports in Tableau and Cognos
• Strong experience in designing efficient metadata models using Cognos Framework Manager and data modules
• Level of comfort collaborating with business partners to define, identify, detailed documentation of project requirements and solutions while proposing valuable design and analytical solutions
• Keen focus to ensure effective deployment and use of dashboards and reports by project, with a focus on quality monitoring and evaluation
• Ability to combine technical skills in Tableau and Cognos with an understanding of health care data and business processes and oversight
• Extensive experience managing schedules/timelines and structuring projects in an iterative fashion while delivering in accordance with overlapping deadlines
• Excellent communication and presentation skills, ability to independently and within a team and to employ effective teaching strategies with diverse audiences

Required Skills

1. Advanced ability to identify and translate business requirements into technical and informational solutions Required 5 Years
2. Strong SAS and SQL experience including jointing multiple tables to extract data in large, complex, and normalized data warehouse. Required 3 Years
3. Strong ability to effectively diagnosis, isolate, and resolve complex problems pertaining to data and its infrastructure Required 5 Years
4. Advanced Tableau experience developing sophisticated dashboards and visualizations. Required 5 Years
5. Strong Tableau administrator skills related to scheduling, folder/project management, user access, and dashboard performance. Required 3 Years
6. Desirable to have experience with health care, especially Medicaid claims data, encounter data, and information. Desired 3 Years
7. Hands on ETL tool experience Desired 3 Years
8. Please attach samples of high quality Tableau dashboards that the candidates have personally created and can walk us through. Required
9. 3 years of experience with and is currently working with Cognos and creating complicated Tableau dashboards Required 3 Years

 
 

Clipped from: https://www.dice.com/jobs/detail/baf090460f1c19647c020faa7fac450e?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic