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Humana Principal, Clinical Business Development (Medicaid) Job in Remote | Glassdoor

Description

The Market Development Principal provides support to assigned health plan and/or specialty companies relative to Medicare/Medicaid/TRICARE product implementation, operations, contract compliance, and federal contract application submissions. The Market Development Principal provides strategic advice and guidance to functional team(s). Highly skilled with broad, advanced technical experience.


Responsibilities



The Medicaid Behavioral Health Business Development Principal provides support to assigned business development team and/or specialty companies relative to Medicaid mental health and substance abuse business strategy and solutioning, implementation, operations, contract compliance, and federal contract application submissions. The Market Development Principal provides strategic advice and guidance to functional team(s). Highly skilled with broad, advanced technical and Medicaid behavioral experience.


Responsibilities


The Medicaid Behavioral Health Business Development Principal serves as the primary resource and SME for business development. Ensures that RFP content and clinical model is meeting or exceeding corporate and state Medicaid requirements. Works with senior executives to develop and drive segment or enterprise-wide functional strategies. Advises one or more areas, programs or functions and provides recommendations to senior executives on matters of significance, and as an advanced subject matter expert competent to work at very high levels in multiple knowledge and functional areas across the enterprise.


Required Qualifications

  • Bachelors Degree
  • Experience in fully integrated physical and behavioral clinical models
  • 10 years working experience in leading mental health and substance abuse Medicaid strategy for complex populations
  • 10 years working experience in leading Medicaid strategy for complex populations
  • 10 or more years of program design, execution and measurement in the Medicaid population
  • 5 years of project/people leadership
  • Experience as subject matter expert in Medicaid RFP process
  • Strategic thinking and planning capabilities
  • Organized and detail-oriented
  • Excellent presentation and communication skills, both internal and external audiences
  • Must be passionate about contributing to an organization focused on continuously improving consumer experiences
  • Able to effectively work in matrix organization and influence senior leadership level key stakeholders

Preferred Qualifications

  • Graduate Degree
  • Experience evaluating competitor capabilities, determining where there are gaps and making recommendations to close them

Additional Information

•Limited travel


Scheduled Weekly Hours


40

 
 

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Medicaid Care Coordinator (REMOTE) at CRS Group – Tarta.ai

Medicaid Care Coordinator (REMOTE)

Duration: 6+ month contract (likely to extend)

Location: Chicago, IL 60601

Pay Rate: $24.45/hr

 
 

Overview: The CRS Group is currently looking for a Medicaid Care Coordinator (REMOTE) for one of our clients in the Chicagoland area. The CRS Group is a nationwide Staffing Firm who works primarily with Fortune 500 and Fortune 1000 corporations.

 
 

Duties and Responsibilities:

  • This position is responsible for monitoring Medicaid/Medicare and related regulations and policy changes impacting clinical operations
  • Participating in audits
  • Supporting tracking and submission of Medicaid State Contract(s) related deliverables, including fulfillment of internal and contractual reporting requirements
  • Working with other areas of the organization on the development, testing and implementation of organization, process and system changes to ensure the requirements of the Medicaid program are met
  • Assisting MMP in coordination of the contract with the State/CMS enterprise-wide.

Qualifications:

  • Bachelor Degree in Business OR 2 years’ experience with health insurance.
  • 1 year of experience with health insurance benefits and/or operations.
  • Knowledge of Medicaid and Medicare product(s).
  • Verbal and written communication skills.
  • Experience presenting trends and findings in meetings with management.
  • Experience organizing multiple tasks and responsibilities.
  • Experience analyzing data reports.
  • Experience developing and running queries in a database.
  • PC proficiency to include Microsoft Word, Excel, PowerPoint, and Outlook
  • Knowledge of health benefits.
  • Knowledge of Health Plan Clinical Operations.

 
 

Clipped from: https://tarta.ai/company/crs-group/job/medicaid-care-coordinator-remote-in-chicago-il?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

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CNSI Project Manager (Medicare, Medicaid, or Healthcare verticals) – Remote Position Job in Atlanta, GA

Working remotely within the United States is acceptable for this position.

What you will do:

Oversees one or more software products end-to-end and assists in the direction of particular project-level activity and associated team personnel.
Works under general supervision.
Maintains relationship with client, project scope can increase in complexity and size.
Manages client relationships at the client customer work site.
Provides project management for prime or sub-contractor, fixed price, or time and materials projects.
Provides project management on projects with a team size that is up to 100 employees concurrently.
Provides project management on projects with annual total contract value of up to $50M and complexity (hours) of up to 300,000 hours.
Provides end-to-end responsibility for one or more products, sub-systems or level responsibilities.
Develops detailed, resource loaded project schedule with the required metrics.
Confers with project personnel to provide technical advice and to resolve problems.
Manages project risk by working with project schedulers to track project schedules, deliverables, and milestones; monitors costs and schedules using EVM and other tools.
Oversees and develops a feasible plan for one or more software products that achieves the goals and objectives of the project and aligns with the organization’s overall business strategy.
Assists in developing a feasible plan that achieves the goals and objectives of the project and aligns with the organization’s overall business strategy.
Determines project scope and recommending and assigning resources as available.
Determines estimated time and financial commitment of project, and in monitoring progress.

General:

Implements, maintains, and reports Earned Value (EV) metrics into project plans.
Implements, maintains, and reports CNSI project delivery metrics into project plans.
Assists in monitoring and developing a project budget and tracking actual spend compared to the planned budget, escalating to senior leadership as needed.

Customer:

Partners with customers and analyzes issues and problems from the customer perspective.
Provides customer-facing presentations on quality.
Communicates and provides status to define, schedule, and accurately estimate the task duration for project schedule.
Possesses unwavering commitment to customer service and operational excellence.
Keeps abreast of new technology and market developments.
Adheres to CNSI CMMI standards and processes.
Manages internal customer relationships for long-term corporate success

Talent Development:

Requests and gives both negative and positive feedback.
Recruits highly skilled, motivated leaders and individual contributors and recommends potential new hire resources to meet client commitments in alignment with program delivery.

Project:

Familiarity with medical bill and provider enrollment forms.
Identify reoccurring problems and provide feedback to management to affect change.
Familiarity with payment adjustments, claim disputes, prior authorization, claims processing,
Manage sensitive data in accordance with HIPAA and Medicaid regulations.

About us:

We are proud to be a partner to the public sector, a trail blazer in health IT and a passionate advocate for better health, better care and lower costs for millions of Americans. Innovation is core to our DNA and through our iCare program we invest in the well-being of our employees and the communities in which we live and work. You will be offered a solid compensation package which includes:

 
 

  • Annual and Other Paid Leave
  • Medical/Dental Insurance
  • Flexible Spending Account (FSA) Plan
  • Disability Insurance (Short & Long Term)
  • Life Insurance
  • 401(k) Retirement Savings Plan
  • Employee Assistance Program
  • College Savings Plan
  • Tuition & Training Assistance
  • Paid Holidays
  • Employee Referral Program

 
 

CNSI maintains a policy supporting equal employment opportunity. Employment decisions at CNSI are made without regard for race, color, religion, sex, national origin, age, disability, sexual orientation, gender identity, marital status, genetic status, family responsibilities, protected veteran status or any other status protected by applicable Federal, state, or local law. We are proud of our diversity and encourage all qualified applicants to apply.

 
 

#LI-CV1

Experience

Required

  • 15 year(s): Experience in project planning, delivery, and management
  • 2 year(s): Experience in provider management, claims processing, prior authorization, and/or other related projects.
  • Demonstrates leadership skills and ability to work effectively with different teams and contributors both directly and in a matrix environment.
  • Domain knowledge of Medicare, Medicaid, or healthcare verticals.
  • Ability to manage people, projects, and processes.
  • Strong understanding of project management skills and ability to create and manage project plans.
  • Expertise in Microsoft Schedule
  • Understanding of SharePoint applications, WebEx, Skype, etc.

Preferred

  • Familiarity with medical bill forms, ICD-9/10CM coding, CPT coding, bill forms, and other medical coding schemes.
  • Ability to meet and enforce deadlines, to conduct research into technology issues and products, and to take initiative in the development and completion of projects.
  • Knowledge of Microsoft Word, Excel, and Visio with a working knowledge of the rest of the Microsoft Office suite of applications.
  • Strong knowledge of Microsoft Project EV metrics.
  • Strong problem-solving, analytical, and evaluative skills.
  • Strong communication skills (verbal, written, facilitation) with strong presentation and facilitation skills.
  • General knowledge of medical terminology

Education

Required

  • Bachelors or better

Preferred

  • Masters or better

Licenses & Certifications

Required

  • Prof in Project Mgmt Cert

Behaviors

Required

  • Team Player: Works well as a member of a group
  • Leader: Inspires teammates to follow them
  • Functional Expert: Considered a thought leader on a subject
  • Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well

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©

 
 

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Health Survey Specialist / Service Advocate- Work at Home Job in Louisville, KY at Aetna

Req ID: 71883BR Job Description Program Overview Help us elevate our patient care to a whole new level! Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our Dual Eligible Special Needs Plan (DSNP) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges.

With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members’ health care and social determinant needs. Join us in this exciting opportunity as we grow and expand DSNP to change lives in new markets across the country. Fundamental Components included but are not limited to: Position Summary The Health Survey Specialist plays a critical role within the DSNP team.

The Health Survey Specialist outreaches DSNP members via phone to introduce the DSNP services and complete the Health Risk Assessment (HRA). The HRA is the first step in creating the member’s Individualized Care Plan and sets the foundation for follow up care management by assessing a member’s medical, functional, cognitive, psychosocial, and mental health needs. Fundamental Components + Uses motivational interviewing and other consultative techniques to gather comprehensive information about a member’s medical, functional, cognitive, psychosocial, and mental health needs + Accountable to the highest level of compliance integrity + Champions for the member by connecting members with urgent needs to the appropriate Aetna team, including DSNP’s interdisciplinary care team and customer service + Initiates engagement with assigned members to introduce the program and drive active participation in completion of their Health Risk Assessment + Builds a trusting relationship with the member by engaging the member in meaningful and relevant conversation, prior to and during assessment + Effectively supports members during enrollment calls, appropriately managing difficult or emotional member situations, responding promptly to member needs, and demonstrating empathy and a sense of urgency when appropriate + Conducts triage, connecting members with appropriate care team personnel including care managers and customer service when needed + Accurately and consistently documents each call in the member’s electronic record, thoroughly completing required actions with a high level of detail to ensure we meet our compliance requirements + Protects the confidentiality of member information and adheres to company policies regarding privacy/ HIPAA + Ability to be agile, manage multiple priorities, and adapt to change with enthusiasm + Determined to build strong relationships with peers and our DSNP members + Demonstrates an outgoing, enthusiastic, and caring presence over the telephone Qualifications Requirements and Preferences: + At least 3 years of experience in health care, customer service, telemarketing and/or sale + Familiarity with basic medical terminology, health care, and the concepts of care management + Medicare/Medicaid/DSNP experience preferred + Experience with computers, including knowledge of Microsoft Word, Outlook, and Excel required + Strong organizational skills, including effective verbal and written communications skills required + Data entry and documentation within member records is strongly preferred + Flexibility with work schedule to meet business needs + Bilingual desired Education and Certification Requirements + High School diploma or G.E.D.

required + Associates/Bachelor’s degree preferred Benefit Eligibility Benefit eligibility may vary by position. Job Function: Customer ServiceAetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.

 
 

Clipped from: https://www.ziprecruiter.com/c/Aetna/Job/Health-Survey-Specialist-Service-Advocate-Work-at-Home/-in-Louisville,KY?jid=803c0c97550317ef&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Posted on

Medicaid Claims & Encounters Senior Advisor- Work From Home Opportunity – Cigna

 
 

Remote or Bloomfield, CT

$162,366 yearly est.

**Job Summary:**

_Medicaid Claims & Encounters Senior Advisor position_ is the _encounters_ subject matter expert and responsible for working with IT and Claims and other operational areas, to ensure the accurate, timely and efficient submission of claims and encounters.


Works with IT and business leadership (corporate and market based) to effectively provide access to information and data to maintain business lead by the organization of state and federal regulatory reporting.


Together with internal functional partners, ensure we meet or exceed Medicaid and Medicare claims and Encounter requirements related to the State of Texas Medicaid and MMP programs and internal goals. Perform various analysis and interpretation to link business needs and objectives for assigned function by:


+ Support business initiatives through data analysis, identification of implementation barriers and user acceptance testing of various systems.


+ Ensuring Encounter submissions meet state requirements. Perform necessary data pulls and analytics to pre-determine failures in encounter data extracted from claims system.


+ Identify and analyze user requirements, procedures, and problems to improve existing processes.


+ Ensure BA’s and other analysts processing files are keeping up to date, informed of changes and following through with them.


+ Complete the monitoring of submission, transmission and acceptance rates and provide reporting around each as required.


+ Reviewing, researching, investigating and correcting encounter issues through data and process analysis.


+ Where process or system changes are necessary, develop short and/or long-term resolutions by identifying root causes using data files, provider files, diagnosis files, etc.


+ Develop collaborative relationships with internal partners to ensure Encounter goals are met; includes partnering with functional teams (e.g., Provider Data, Claims, etc.) accountable for issues impacting Encounters.


+ Resolve issues and problems by conferring with those internal and external clients as necessary.


+ Support internal and external partners for reporting requirements.


+ Analyze the integrity of data, diagnose issues and test changes.


+ Participates in change management procedures to support accurate data documentation and process flow supporting the reporting requirements.


+ Develop and maintain all Encounter reporting technical documentation.


+ Maintain Encounter reporting describing results against internal goals; presenting results and issue updates


+ Develop, share, and incorporate organizational best practices into business applications


+ Develop relationships with state partners to research issues.


+ Regularly (Quarterly) review processes and work collaboratively with other BA’s and other analysts to improve automation and accuracy of submissions.


+ Identify trends / issues / deficiencies regarding monthly submission files and feedback files; oversee or resolve errors by working with other key departments; determine whether there is a need for process improvement or modification to ensure proper submission of all encounters; document testing; maintain record / file of all these interactions and of any changes.


+ Serves as Medicare and Medicaid Encounter Subject Matter Expert (SME) for state of Texas and other states acquired as necessary.


+ Support management requests for reporting based on various performance measures/data within the organization


+ Lead system testing to validate the rollout of new functionality.


+ Ability to perform some travel.


+ Other duties as assigned by supervisor/organizational leadership.


+ Maintain professional contact with other departments as needed; attend interdepartmental meetings.


**Minimum Qualifications:**


+ Bachelor’s degree preferred or equivalent experience.


+ 4+ years of business process analysis, preferably in healthcare (i.e. documenting business process, gathering requirements) or claims payment/analysis experience.


+ Experience with encounters or claims business analysis experience in healthcare, preferably managed care or Medicaid Advanced knowledge of Microsoft Applications, including Excel and Access preferred.


+ Experience in benefits, pricing, contracting or claims and knowledge of provider reimbursement methodologies. Knowledge of managed care information or claims payment systems preferred.


+ Previous structured testing experience preferred. Compliance Coding/Prepay Compliance (Payment Integrity).


+ Knowledge of HIPAA transactions (i.e. 837, I, P, 999, 824, 277,820, 834) and SQL Scripting preferred.


+ Experience managing projects with a high reliance on technology.


+ Experience in Project Management


This position is not eligible to be performed in Colorado.


**About Cigna**


Cigna Corporation (NYSE: CI) is a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. We offer an integrated suite of health services through Cigna, Express Scripts, and our affiliates including medical, dental, behavioral health, pharmacy, vision, supplemental benefits, and other related products. Together, with our 74,000 employees worldwide, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation.


When you work with Cigna, you’ll enjoy meaningful career experiences that enrich people’s lives while working together to make the world a healthier place. What difference will you make? To see our culture in action, search #TeamCigna on Instagram.


_Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws._


_If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response._

Clipped from: https://www.zippia.com/bloomfield-ct-jobs/senior-advisor-dlp/?dc1697071cbed0446f8f52619dd4f104aef607c0&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

 
 

Posted on

DSNP Member Advocate – Work At Home

CVS Health

La Place, LA Full-timeWork from home

  • Help us elevate our patient care to a whole new level!
  • Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models.
  • You can have life-changing impact on our Dual Eligible Special Needs Plan (DSNP) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges.
  • With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members’ health care and social determinant needs.
  • Join us in this exciting opportunity as we grow and expand DSNP to change lives in new markets across the country.
  • Required Qualifications The Member Advocate works alongside other DSNP care team members including social workers, care managers and care coordinators to provide the best member experience.
  • Educates and assists members on various elements of Medicaid entitlements, benefit plan information and available services created to enhance the overall member experience with the company.
  • Utilizes all relevant information to effectively influence member engagement.
  • Initiates contact with members who have lost Medicaid eligibility and fall into DSNP grace period to remind them to reobtain Medicaid and LIS recertification.
  • Assists members with finding resources to help them reapply if necessary.
  • Coordinates and sends annual reminders for members at risk of losing LIS, Medicaid, or DSNP eligibility.
  • Takes ownership of each customer contact to anticipate customer needs, resolve their issues and connect them with additional services as appropriate.
  • Tracks member’s Medicaid certification and eligibility dates and MCO plan information, as well as Medicaid status.
  • Researches other general Medicaid programs and entitlements the members are eligible for and initiate process to inform members of these benefits.
  • Completes accurate case documentation as needed.
  • Works with National DSNP Program Office Medicaid Policy Manager and State Contract Manager to provide general assistance with Medicaid benefits and entitlements.
  • Preferred Qualifications In-depth knowledge of benefits program and system design (Health and Welfare, Wealth, other benefits), related financials, legal/regulatory requirements.
  • Knowledge and understanding of state policy or Medicaid eligibility and low-income state resources.
  • Strong collaboration skills and innovative problem-solving abilities.
  • Strong verbal and written communication skills.
  • Ability to work independently, accurately, and e efficiently.
  • Innovative Thinking and “Change Agent” Looks for, identifies and acts on opportunities to improve how we design, develop, and deliver products and services.
  • Empathy towards customers’ needs and concerns.
  • Education Associate’s degree or equivalent work experience.
  • Business Overview At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health.
  • We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused.
  • Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
  • We are committed to maintaining a diverse and inclusive workplace.
  • CVS Health is an equal opportunity and affirmative action employer.
  • We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status.
  • We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

Posted 18 days agoInactive Job

Links for CVS Health

 
 

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Medicaid Transportation Advocate

 
 

Medicaid Transportation Advocate (54561)

Remote Opportunity To Work From Home!
Must live within a commutable distance of Syracuse, NY

HOURS: Monday – Friday 9:30am – 6:00pm or 11:30am – 8:00pm

PAY RATE: $16/hr.

CPS Recruitment is partnering with an established, 24-hour Call Center in Downtown Syracuse, NY to find 10 Medicaid Transportation Advocates to become a vital part of their growing team!

Work for a leading Medicaid transportation company that offers full-time and temp-to-hire opportunities.

If you have a positive attitude, enjoy working in a team environment and have excellent customer service skills – apply today!

Training begins 11/30/2020!

Duties & responsibilities include, but are not limited to, the following:

  • Answer a high volume of inbound calls in a professional and courteous manner
  • Monitor driver trips
  • Override invoices
  • Escalation calls
  • Assist employees with questions
  • Ensure full Medicaid compliance
  • Assist with vendor relations and county specific tasks
  • Other duties assigned by management

Minimum Qualifications:

  • High School Diploma or GED
  • Healthcare or Medicaid background desired
  • Able to work with management
  • Excellent customer service skills
  • Able to handle difficult calls

Applicants must follow the CPS employment guidelines and be willing to comply with our drug screening policy and other pre-employment requirements.

How to Apply:
For consideration please submit a resume to the following:
Email: jobs@cpsrecruiter.com
Further questions, call 315-883-5507

CPS Recruitment is an Equal Opportunity Employer

CPS Recruitment is an Equal Opportunity Employer.

 
 

Clipped from: https://www.glassdoor.com/job-listing/remote-medicaid-transportation-advocate-54561-cps-recruitment-JV_IC1132872_KO0,45_KE46,61.htm?jl=3761872664&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Posted on

Medicaid Quality Management Health Plan Director – Anthem, Inc.

 
 

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 benefits companies and a Fortune Top 50 Company.


Title: Medicaid Quality Management Health Plan Director


Location: Colorado


(The position will start out as work from home but most likely transition to the office when offices re-open)


Status: Full-time, Salary, Bonus Potential


The Medicaid Quality Management Health Plan Director is an individual contributor role that is responsible for driving the development, coordination, communication, and implementation of a strategic clinical quality management and improvement program within assigned health plan. Responsible for working with the regional head of quality management to direct the clinical quality initiatives, including HEDIS and CAHPS quality improvement, NCQA accreditation and compliance with regulatory agencies and other objectives.


Primary duties may include, but are not limited to:


+ Works with both internal and external customers to promote understanding of quality management activities and objectives within the company and to prioritize departmental projects according to Anthem corporate, regional, and departmental goals.


+ Maintains expert knowledge of current industry standards, quality improvement activities, and strong medical management skills.


+ Serves as a resource for the design and evaluation of process improvement plans/quality improvement plans and ensures they meet Continuous Quality Improvement (CQI) methodology and state contractual requirements.


+ Collaborates with other leaders in developing, monitoring, and evaluating Healthcare Effectiveness Data Information Set (HEDIS) improvement action plans, year round medical record review, and over read processes.


+ Monitors and reports quality measures per state, Centers for Medicare and Medicaid Services (CMS), and accrediting requirements.


+ No direct reports or supervisory duties


Qualifications


+ Requires BA/BS in a clinical or health care field (i.e. nursing, epidemiology, health sciences)


+ 5 years progressively responsible experience in a Healthcare- Quality Management environment for a provider or payer


+ Extensive knowledge of Medicaid


+ Any combination of education and experience, which would provide an equivalent background.


+ Live in the state of Colorado


+ MS or advanced degree in a health care related field (i.e. nursing, health education) or business strongly preferred.


+ Previous experience working with NCQA, and HEDIS preferred.


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.


REQNUMBER: PS43608-US

 
 

Clipped from: https://www.zippia.com/nashville-tn-jobs/planning-director-dlp/?78027b921e4ec740ede050eb2a115b399a093997&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

 
 

Posted on

Management Consultant – IV&V Medicaid Job at Public Knowledge in Colorado

 
 

Management Consultant

Applicants must be willing to travel and should be within an hour of a major airport.

Company Summary

Public Knowledge is a national management consulting firm that helps government agencies solve tough problems and thrive in complex environments. We do this by providing planning, procurement, and implementation services. Most of our work is in Health and Human Services. You can learn more about us at www.pubknow.com. GLI® Group has acquired Public Knowledge, which provides Public Knowledge with the financial backing and infrastructure of a larger company.

Position Summary

This management consultant would spearhead research efforts to gather information for large projects and programs and propose creative solutions. This person would collaborate with project managers and team members to support project administration, time management, and budgeting.

Duties & Responsibilities include, but not limited to:

Research

  • Gather information for a project by conducting interviews, surveys, facilitating groups, analyzing client documentation, conducting research of best practice and academic literature, and the application of other information gathering tools.

Project Support

  • Learn and apply the tools and techniques we have for projects.
  • Work with project managers to support the administration of projects (ensure staff adhere to standards, organizing the time of other team members, supporting project meetings, and assisting with project financial management).
  • Help your team meet project objectives, timelines, and deliverables within budget.

Analysis, Communication, and Consultation

  • Using your experience and research results, analyze and organize information identifying root causes of issues, opportunities for improvement, and generate ideas to improve the client situation.
  • Based on your analysis, research, and experience participate with your team in the development of recommendations for actions that will improve the client situation.
  • Communicate the results of our work (information, analysis, and recommendations) through the participation in the development and delivery of written reports, formal presentations, and oral discussions with your team, and as requested clients and stakeholders.

Firm Knowledge Sharing and Growth

  • Freely share your knowledge, skills, and abilities with your peers in the firm.
  • Perform firm administrative activities (maintain your resume, record your time accurately).
  • Grow your skills and experience by participating in projects and actively pursuing continuing professional education.
  • Develop an effective working relationship with clients and colleagues.

Required Education and Other Credentials:

  • Bachelor’s Degree required
  • Valid Driver’s License
  • PMP certification is strongly preferred

Required Experience and Skills:

  • At least three (3) years of project management experience, preferably in major IT systems-related work.
  • At least three (3) years of experience conducting IV&V work, preferably in health or major IT systems-related work.
  • Experience in systems development best practices and knowledge of the typical artifacts created as part of a system development project is required. Knowledge of Medicaid and or Integrated Eligibility is a requirement and familiarity with MITA. Knowledge of multi-project integration programs and multi-system data consolidation efforts is preferred.
  • Knowledge of the components of Software Development Life Cycle and best practices including all waterfall and agile frameworks as well as SaaS, COTS, and Custom design solutions
  • Deep knowledge of Medicaid and Health IT that spans the development and testing of systems through the operation of the programs the technology supports
  • Proven ability to report observations, conclusions, and making recommendations for improvement about project problems and issues; ability to focus and to be objective on the assessment of SDLC processes and products
  • Must have experience in bringing focus and organization to ambiguous situations
  • Must demonstrate creative and strong analytical and problem-solving skills
  • Demonstrates excellent interpersonal skills Must have flexibility and ability to adapt quickly to new situations
  • Must have ability to establish and cultivate strong work relationships
  • Must have clear, concise written and verbal communication
  • Must have demonstrated life-long learning skills
  • Desire to work in a collaborative, fast-paced, entrepreneurial environment
  • Ability and willingness to travel (reasonable travel will be required)
  • Proficient knowledge of Microsoft Word, Excel, and Outlook
  • Must have excellent oral and written communication skills, including the ability to communicate with officials at all levels in government and industry
  • Must have the ability to handle and organize multiple projects and deadlines
  • Must demonstrate a high degree of attention to quality, details, and correctness
  • Ability to work with colleagues in a virtual environment (via conference calls, web meetings, and using digital collaboration tools such as Zoom and cloud document repository)

Physical Requirements and Working Conditions:

  • Must have the ability to travel to client sites
  • Ability to work from a home-based office
  • Must have the ability to work at a computer for extensive periods of time
  • Must have the ability to speak on the telephone for extended periods of time
  • Must have the ability to read (paper or computer screen) for extended periods of time
  • Must have sufficient hand, arm, and finger dexterity to operate a computer keyboard and other Company equipment
  • Must have the ability to be self-driven, work independently and as part of a team

We offer excellent benefits that include:

  • Comprehensive Health and Dental Insurance
  • Retirement Plan
  • Disability Benefits
  • Flexible Work Hours
  • Generous Vacation Program

Applying

Think you’ve got what it takes? Apply online at on our website and include an introduction to yourself and your qualifications.

This job post should not be interpreted as all-inclusive; it is intended to identify major responsibilities and requirements of the job. The incumbent may be requested to perform other job-related task and responsibilities than those stated above.

Public Knowledge is an Equal Opportunity Employer

 
 

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Posted on

The Medicaid Subject Matter Expert(SME)

JobDescription
Summary:


The Medicaid Subject Matter Expert(SME) will provide support in the area of proactive data analysis used toidentify investigative targets in the Medicaid Program. The SME will performfraud, waste and abuse detection, deterrence and prevention activitiesinvolving Medicare and Medicaid providers, suppliers, and other entitiesreceiving reimbursement under one or both of the Medicare and Medicaidprograms. This includes providers,suppliers, and other entities performing under Medicare Advantage, the MedicarePrescription Drug Program (Part D), Medicaid Managed Care, and other programsadministered or operated by CMS or State Medicaid Agencies for Medicare claimsprocessed within the jurisdiction.


Duties/Responsibilities:


· Providesubject matter expertise and technical assistance on matters related toMedicaid policies and regulations.


· Identificationof proactive data studies in the Medicaid program, resulting in identificationof high ROI fraud schemes in the Medicaid program in IL, IN, IA, KS, KY, MI, MN,MO, NE, OH and WI


· Generateinvestigative leads related to trending fraud schemes


· Remaininformed of current Medicaid fraud and abuseissues/schemes through researching reports such as CMS MIG Reviews, OIG StateReports, National Association of Medicaid Directors (NAMD) Briefs and otherresources included in the Medicaid SME Research list


· Identifyand document state program vulnerabilities


· AttendMedi-Medi meetings with external customers


· Ensureconfidentiality of all PHI and sensitive information


· Travelas required for meetings or training


· Performother duties as assigned


Minimumrequired qualifications/skills:


· BA or BS degree


· Minimum of three (3) years of Medicaidexperience is required


· Experience in program integrity or medicalreview


· Excellent oral, written and verbal skills with experiencecompiling data and writing reports


· Ability to work independently with minimalsupervision in a fast-paced environment with strict deadlines


· High proficiency level with Microsoft Excel andWord


· Working knowledge of Microsoft PowerPoint


· Excellent research skills including internetresearch


· Ability to work independently with minimalsupervision


· Must have and maintain a valid drivers licenseissued by state of residence


Preferredqualifications/skills:


· Certified Fraud Examiners (CFE) designationand/or Accredited Healthcare Fraud Investigator (AHFI) designation


SupervisoryResponsibilities:


· None


Location:


· Work from Home


OfficeEquipment (if a WFH position):


· A locking cabinet and/or desk appropriate for storingdocuments and electronic media


· A cross-cut or micro-cut (preferred) shredder


· A broadband internet connectionwith minimum download speed of 15MB – 20MB. (Wireless Air Cards are not approved forwork from home use. Free/public wi-fi connections not approved.)


· Telework office connection can be hard-wired direct orWi-Fi connection. Minimum of WPA2 (Wi-Fi Protected Access II); prefer WPA2 +AES. (WPA and WPE are not approved.) Recommended home wireless standards: WirelessG Goes through walls, but Medium speed. (Use if router not visible); WirelessN – Great for Speed, but not effective through walls. (Use if router visible); WirelessAC – High speed, but not effective through walls or distance. (Use if routervisible)


· Separate phone line (can be a cell phone)


· Office equipment (such as laptop and printerwill be provided)


PhysicalRequirements:


· May require prolonged periods of sitting at adesk.


Other:


· Successful candidates will be required to consentto background checks, credit check and other contract related screenings


· Travel may be required, and all travel expenses, if applicable,are reimbursable via GSA standards

 
 

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