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Senior Provider Contracting Professional – Ohio Medicaid job in Cincinnati, OH | Humana Inc.




The Senior Provider Contracting Professional initiates, negotiates, and executes physician, hospital, and/or other provider contracts and agreements. The Senior Provider Contracting Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.


The Senior Provider Contracting Professional negotiates contract terms, payment structures, and reimbursement rates to providers. Analyzes financial impact of contracts and terms. Maintains contracts and documentation within a tracking system. Identifies and recruits providers based on network composition and needs. Helps to influence department’s strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.

Required Qualifications

  • Bachelor’s degree
  • 3 or more years of progressive network management experience including hospital contracting and network administration in a healthcare company
  • Experienced in negotiating managed care contracts with large physician groups, ancillary providers and hospital systems.
  • 1-2 years of experience working with Ohio Medicaid with understanding of Ohio Medicaid compliance
  • Proficiency in analyzing, understanding and communicating financial impact of contract terms, payment structures and reimbursement rates to providers.
  • Excellent written and verbal communication skills
  • Ability to manage multiple priorities in a fast-paced environment
  • Proficiency in MS Office applications
  • Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

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

Additional Information

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

Scheduled Weekly Hours



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CareFirst BlueCross BlueShield Supervisor, Utilization Management (MD Medicaid) Job in Owings Mills, MD


Resp & Qualifications


Supervise the daily operations of the utilization management (UM) department functions to ensure appropriate coordination of health care services and compliance with UR policies/procedures, as well as, regulatory and CareFirst’s accreditation standards.


This position reports to the Utilization Review Manager. Primary accountabilities include, but are not limited to, the following:

Manages the delegation of assignments and supervises UR associates. Routinely assesses and evaluates UR associate workloads/functions for compliance to process and standards, appropriateness in quality of work and productivity. Assists/directs handling of complex cases to ensure appropriateness for documentation and inclusion of other internal departments, including but not limited to Physician Reviewers, Central Appeals, etc. Collaborates and acts as a resource to UR staff and other internal customers regarding UR process, including, but not limited to, benefit contracts, coordination of care, adverse decisions, problem solving, or development of interdepartmental workflows. Performs Utilization Review when coverage warrants.

Provides mentoring and guidance to develop, expand and improve associates’ skills and expertise. Conducts individual and regular staff meetings to maintain ongoing communication. Conducts inter-rater reviews, providing feedback on a quarterly basis or more often as indicated by performance. Ensures that UR associates have the information and resources needed to accomplish their assignments. Works with UR Supervisors and/or trainer to coordinate the orientation program for new associates, including evaluation of new associate performance as per UR policy/procedures.

Actively participates in the development, design, and implementation of utilization review processes and procedures or new CareFirst programs as assigned by Manager. Maintains UR policies and procedures to ensure UR process and goals are supported; this includes an annual review of policies and procedures. Maintains current knowledge of regulatory and/or accreditation standards. Ensures that the required elements for the standards are current and incorporated in the UR process. Performs projects or other tasks as delegated. Uses/analyzes UR data to provide insight regarding trends, staffing, case load ratio, etc., that could impact the UR process. Performs projects or other tasks as delegated.

Communicates in a timely manner to Manager appropriate information including, but not limited to, customer/case issues, reports, trends/variances, action plans, etc. Meets routinely with peers, staff and/or Manager to communicate/update as pertinent. Acts as a liaison with external customers to ensure coordination of care and services as appropriate for effective management of benefits and quality of care. Plans and implements meetings with provider community to proactively facilitate change, improve service and coordinate UR activities.



To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The
requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable
accommodations may be made to enable individuals with disabilities to perform the essential functions.

This position requires an active RN license in the CareFirst region with five years of medical/surgical experience including, but not limited to, inpatient care, outpatient/home care and hospice care, three years experience reviewing patient medical care and one year in a supervisory role or equivalent work experience in team leadership, training or project management.

Preferred Qualifications:

Bachelor’s degree in Nursing with one to two years of experience in managed care. Thorough knowledge of CareFirst clinical guidelines, medical policies and accreditation and regulatory standards relating to utilization review. Experience in claims review and in using, diagnosis and procedure codes.

Knowledge, Skills and Abilities (KSAs

Knowledge of accreditation standards and federal/state regulations and general principles relating to
utilization review. Advanced
Computer skills, including Microsoft Office programs. Proficient
Ability to mentor and coach associates to accomplish goals, provide objective evaluation of associate
performance, and implement strategies to improve individual and team-based performance as needed. Proficient
Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for
flexibility Expert
Excellent analytical, problem-solving skills with ability to judge appropriateness of member services and
treatments on a case by case basis Expert
Effective written and interpersonal communication skills to engage with members, healthcare
professionals, and internal colleagues Advanced

Additional Skills and Abilities
The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her
ineligible to perform work directly or indirectly on Federal health care programs. Must be able to effectively work in a
fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long
periods of time. Must be able to meet established deadlines and handle multiple customer service demands from
internal and external customers, within set expectations for service excellence. Must be able to effectively
communicate and provide positive customer service to every internal and external customer, including customers
who may be demanding or otherwise challenging.

Licenses and Certifications
RN – Registered Nurse – Maryland, Washington, DC or Compact State


Department: MD Medicaid -HEALTH SERVICES

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply:

Closing Date

Please apply before: 8/19/21

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.


The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship


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Director Medicaid Programs | Chicago, IL | HCSC


This position is responsible for directing the activities related to the business operations of the Medicaid Managed Care operations in accordance with contractual and regulatory requirements. Directs the development of infrastructure, standards and policies and procedures of program changes and works 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, specifically around claims processing and management, . Organizes, manages, and facilitates, bi-monthly Medicaid Oversight and Operations inter-departmental Team. Also serves as the liaison with vendors and internal functional areas and assists in the coordination of the contract with Medicaid Division for the State and also represents BCBS at key State meetings. This position must ensure that operations run effectively and efficiently, while meeting all contract requirements and performance standards. Provides direction and training to staff. Adherence to compliance and audit requirements is essential. Serves as primary contact for external audits on Medicaid Business; directs the internal activities during such reviews and audits

* Bachelor Degree in Business with 6 years experience OR 10 years experience working in health insurance operations.
* 5 years management experience.
* Demonstrated experience in project management.
* Medicaid operational experience.
* Knowledge of contract and rate reimbursement provisions relating to hospital, home health agencies, nursing facilities, and other Medicaid providers.
* Demonstrated ability to work directly with corporate leadership.
* Leadership, organization, self-motivation and initiative skills.
* Demonstrated ability to manage multiple complex priorities.
* PC proficiency to include Word, Excel, and Lotus Notes.
* Analytical skills and presentation skills.
* Verbal and written communication skills.
* Presentation skills to speak to large audiences and meeting facilitation skills for external agency meetings.


* Experience with government contracts.
* Management experience in a health care or managed care environment
* Experience in the health care industry.

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Manager, Medical Claims Review


Our Mission:  Provide the best value in health insurance and related health services to improve the quality of life for Arizonans.

Our Vision: 

Inspire health in Arizona as the trusted leader in delivering affordable, innovative healthcare solutions.

Our Benefits: Our benefits provide work-life balance and the flexibility you need to be your best. We offer comprehensive medical, dental, and vision coverage; a 401K savings plan; paid holidays and vacations; and much more!

Position Purpose:

The Manager, Medical Claims Review department is responsible for leading a team of nurses and paraprofessionals in reviewing and analyzing medical claims to ensure medical necessity for services rendered, right level of care, correct billing and coding procedures are substantiated for inpatient and outpatient claims. This position requires consistent application of InterQual Criteria and Medicaid and Medicare billing and coding expertise.


  • Develops procedures and processes for team adherence to claim review and documentation based on best practice
  • Write job aids, policies, train staff, and ensure all regulatory standards are met for Medicaid, Medicare, and NCQA
  • Evaluate data and provide direction, course correction, and leads process improvement
  • Coach and mentor staff; work with senior leaders on employee performance issues
  • Directs professionals and paraprofessionals to deliver on all KPIs for the health plan
  • Tracks data, analyzes findings for medical claims decisions, disputes, and provider response
  • Meets with providers in JOCs and as needed
  • Responsible for the day to day operations of the department
  • Conducts claim reviews and provides accurate and detailed abstracts for Medical Director review
  • Maintains and updates authorizations in medical management system and the claims system
  • Collaborates with Network Services leadership to educate providers on correct coding, billing, and clinical documentation

Education / Experience / Other Requirements


  • RN; BSN preferred
  • Arizona unrestricted RN license required
  • Certified coder

Years of Experience:

  • 2-3 years direct clinical experience
  • 1-2 years managed care/health plan experience preferred
  • 1-2 years medical claims review experience
  • Medicaid and Medicare experience preferred
  • Prior management experience 2 or more years

Specialized Knowledge:

  • Claims review tenets
  • Computer skills including MS Word, Excel spreadsheets
  • Communication skills: oral and written

Skills & Abilities:

  • Ability to manage multiple projects and prioritize adhere to deadlines/time frames
  • Ability to supervise and lead others
  • Ability to manage regulatory deliverables

*Position Located in Arizona*


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Medicaid Enterprise Architect


About the job

Medicaid Enterprise Architect

Knowledge of the MITA Business, Information and Technical architectures.

Knowledge of the Medicaid Systems and Solutions.

Experience with data integration and mapping.

Claims and Financial Processing.

Familiarity with HIPAA rules and regulations.

Job Details

Seniority Level

Mid-Senior level


  • Information Technology & Services

Employment Type


Job Functions

  • Design
  • Art/Creative
  • Information Technology

Pay range unavailable

Salary information is not available at the moment.

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Established in 2000, LanceSoft is a Certified MBE and Woman-Owned organization, and a pioneer in providing premium end-to-end Global Workforce Solutions and IT Services to diverse clients across various domains.

LanceSoft’s mission is to establish global cross-culture human connections that further the careers of our employees and strengthen the businesses of our clients. We are driven to use the power of our global network to connect businesses with the right people, and people with the right businesses without bias. We provide Global Workforce Solutions with a human touch.

We offer a gamut of services across diverse domains, categories, skill sets with varying lengths of assignments including:

– Temporary Staffing
– Permanent Staffing
– Payrolling
– Recruitment Process Outsourcing (RPO)
– Application Design and Development
– Program/Project Management
– Engineering Solutions

With currently over 3,800+ staff serving over 110+ enterprise clients worldwide including “Fortune” companies, LanceSoft serves a wide array of industries including Banking & Financial Services, Semiconductor/VLSI, Technology, Healthcare & Life Sciences, Government, Telecom & Media, Retail & Distribution, Oil & Gas and Energy & Utilities.

LanceSoft is headquartered in Herndon, VA with 27 regional offices across the U.S. and 21 offices around the globe. We have five delivery centers in India – Bangalore, Indore, Noida, Baroda and Hyderabad to further serve our clients.

Our awards and accolades in the US Contingent Workforce space:

Accredited by the Better Business Bureau (BBB).
Best of Staffing Client Satisfaction 2021, 2020, 2019
Best of Staffing Talent Satisfaction 2021, 2020
2020 Workforce Logiq Proven Performer (third consecutive year)
2020 SIA Largest Staffing Firms in the US
2020 SIA List of Diversity Staffing Firms
2020 SIA Fastest Growing US Staffing Firms (third consecutive year)
2020 SIA Largest Life Sciences Staffing Firms in the US …


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Analyst, CJ Specialist/Investigator II, Medicaid Investigations Job Opening in Wake County, NC at State of North Carolina


 Wake County, NC Full Time

Job Posting for Analyst, CJ Specialist/Investigator II, Medicaid Investigations at State of North Carolina

THE STARTING SALARY FOR A NEW HIRE TO THIS POSITION IS LIMITED TO THE RECRUITMENT RANGE OF  $ 33,960 to $ 46,713. Salary offers for the selected candidate are based on the candidate’s education and experience related to the position, as well as our agency budget and equity.

The North Carolina Department of Justice, led by the Attorney General of North Carolina, represents the State of North Carolina in court and provides legal advice and representation to most state government departments, agencies, officers, and commissions. The Department also represents the State in criminal appeals from state trial courts, and brings legal actions on behalf of the state and its citizens when the public interest is at stake. 

This position is located in the Medicaid Investigations Division of the Department of Justice.
  The Attorney General’s Medicaid Investigations Division investigates and prosecutes health care fraud committed by Medicaid providers and the physical abuse of patients and embezzlement of patient funds in Medicaid-funded facilities. These cases protect and recover taxpayers dollars that can be used to provide needed medical services to Medicaid enrollees.  These cases also protect our most vulnerable elderly and disabled citizens.

Our Medicaid Investigations Division (MID) is staffed by Department of Justice attorneys, investigators, auditors, analysts, and a nurse investigator, paralegals, and administrative staff.  MID provides state and national training opportunities to aid employees in understanding the complexities of health care fraud investigations.  This position has the opportunity to work cases in state and federal court in partnership with law enforcement agents with federal and state agencies such the Office of Inspector General, FBI, IRS, NC State Bureau of Investigations, Sheriff’s Offices, and Police Departments.

Over the past decade, the NC MID has recovered more than $500 million and helped win more than 450 criminal convictions in health care fraud and abuse cases.

The Attorney General’s office and the Medicaid Investigations Division are committed to ending Health Care Fraud. The link below is provided for your information.

The primary purpose of this analyst position is to provide criminal intelligence and data analysis, data organization and data presentation assistance to Medicaid Fraud Financial Investigators pertaining to investigations of Medicaid fraud and abuse. The employee assists Medicaid Fraud Financial Investigators and one or more teams of attorneys and investigators in the detection, investigation, and punishment of fraudulent and non-fraudulent violations of applicable criminal and civil laws pertaining to fraud and abuse by Medicaid providers and in administration of the Medicaid Program.

This analyst will also support the investigation of Medicare and other federal health care fraud cases and investigations which are primarily related to Medicaid fraud involving complex financial analysis. This individual will

  • prepare detailed spreadsheets and charts, review medical records, prepare written investigative reports, research public records, analyze facts and documents, and assist in the collection and storage of evidence.
  • receive, document, research, gather information, and prepare reports of referrals from citizens, providers, recipients, and other professionals within and outside of the Medicaid agency who report Medicaid fraud abuse.
  • must be able to suggest leads to investigators and assist in preparation of investigative requests for records, subpoenas and search warrants.
  • must also perform administrative duties to include preparation of management reports and other duties as needed.
  • This investigator typically works in the office, but may occasionally be required to work in the field to obtain pertinent information.

The successful candidate must undergo and successfully complete a comprehensive background check as part of the hiring process.

This position is subject to the Fair Labor Standards Act. This position will require travel and overnight travel.


 Note to Current State Employees:
The salary grade for this position is GN08.  State employees are encouraged to apply for positions of interest even if the salary grade is the same as, or lower than, their current position.  Please detail ALL work history including non-state service experience.  If selected for this position, a new salary will be recalculated taking into consideration the quantity of relevant education and experience, funding availability, and internal equity. Based upon these factors, a pay increase MAY or MAY NOT result. 

The State of North Carolina offers employer paid health insurance plus ten paid holidays, generous vacation and sick leave accrual, dental, vision, and other insurance options, and retirement benefits. You can view our benefits information at Employee Benefits. 




Considerable knowledge of criminal justice and law enforcement procedure, terminology, and personnel policies and practices.

Ability to interpret, apply, and communicate statutory regulations of the assigned area.

Ability to analyze, interpret, recommend, and implement policy and procedural guidelines. Ability to instruct and explain standards and procedures.

Ability to establish effective working relationships, including seeking compliance with regulations.

Ability to express oneself clearly and concisely, tactfully and professionally  in oral and written form,

Ability to work independently and use sound judgment in making decisions.

Strong skills in utilizing word processing, spreadsheet, and database software, email functions, and Internet Web browser skills.  The employee must have knowledge of modern office procedures, practices, and equipment including Word, Excel, Access, email, Internet browsers, relational databases, and an effective working knowledge of Medicaid coverage policy and claims processing and data systems. 

Strong organizational skills and file management skills.

Strong problem solving skills; the ability to make inferences and deductions from a vast array of intelligence sources pertaining to criminal activities and organizations.

Must have the ability to learn and adapt to ever-changing computer software; the ability to provide written and oral briefings, reports and training to law enforcement agencies on trends and patterns of criminal activity and new and existing analytical techniques in criminal intelligence; the ability to exercise judgment and discretion in establishing, applying and interpreting policies, procedures, and administrative rules; and the ability to establish and maintain effective working relationships with multi-agency personnel and administrators.

Must comply with rules and regulations regarding confidentiality and the dissemination of information using proper judgment with regard to sensitive and critical information and maintain confidentiality as required by applicable laws and regulations.

The employee must have a thorough knowledge of the intelligence process and methodology. 

Bachelor s degree from an appropriately accredited institution and two years of administrative and/or technical experience in criminal justice or law enforcement as it relates to the area of assignment, or an equivalent combination of education and experience.Please be sure to complete the application in full.

Note the following
: If multiple applications are submitted to an individual posting, only the most recent application received prior to the closing date will be accepted. Applications must be submitted by 5:00 PM on the closing date

Resumes and cover letters:   To receive credit for your work history and credentials, you must list the information on the online application form. This information is used to determine if you meet the requirements of the position, and if you are selected, it is used to determine a salary offer.

Using the terms “See Resume” or “See Attachment” will not be accepted and your application will be rejected as incomplete.  Cover letters are highly encouraged but not required.    

Transcripts:  Degrees must be received from appropriately accredited institutions. A copy of your transcripts indicating the degree received can be uploaded with your application.

If a transcript has been requested, your application will be considered incomplete if  you do not provide one. Using a photograph of your diploma is not acceptable.

Credit for foreign degrees will only be given if verification of degree certification is attached to your application.  Transcripts for foreign degrees have to be evaluated by an organization like World Education Services to determine US equivalency.

Any licenses or certificates must be included in the appropriate section of the application form.

Veterans Preference: Applicants seeking Veteran’s Preference must attach a copy of their DD-214 or discharge orders.

Application status: To check the status of your application, please log in to your account.  Upon the closing date, applications are “Under Review” and will be screened by Human Resources for the qualified applicants. The hiring process may take an average of 6 – 8 weeks.  All applicants will be notified by email once a position is filled.

NeoGov Help Line: 
If you are having technical issues submitting your application, please call the NeoGov Help Line at 855-524-5627. If there are any questions about this posting, other than your application status, please contact the NC DOJ Human Resources office.

The NC Department of Justice is an Equal Opportunity Employer. The NC Department of Justice uses Merit-Based Recruitment to select from among the most qualified applicants to fill positions subject to the State Human Resources Act. 


NC Department of Justice
Human Resources Office
Lisa Sasser, Recruitment Specialist
114 W. Edenton Street
Raleigh, NC 27603

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Actuarial and Reimbursement Intern


Actuarial and Reimbursement Intern


The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, is driven by its mission to deliver comprehensive, cost-effective health care to Arizonans in need. AHCCCS is a nationally acclaimed model among Medicaid programs, and a recipient of multiple awards for excellence in workplace effectiveness and flexibility. Among government agencies, AHCCCS is recognized for high employee engagement and satisfaction, supportive leadership, and flexible work environments, including remote work opportunities. With career paths for seasoned professionals in a variety of fields, entry-level positions, and internship opportunities, AHCCCS offers meaningful career opportunities in a competitive industry. AHCCCS employees are passionate about their work, committed to high performance, and dedicated to serving the citizens of Arizona.

Actuarial and Reimbursement Intern


Posting Details:

Salary: $12.15 hr

Grade: 04

Job Summary:

The Division of Health Care Management (DHCM) is looking for a highly motivated individual to join our team as an Actuarial and Reimbursement Intern. This position may be on a part-time or full-time basis up to but not exceeding six months, depending on the scheduling needs of the Intern. The position will provide the Intern opportunities to work closely with experienced analytical and actuarial staff, apply quantitative skills in support of important agency projects and gain exposure to health finance and state government. During the position, the intern must reside in Arizona and be available to work in-person from AHCCCS’ Phoenix office.

Job Duties:

* Develop queries in Cognos to pull service utilization data. Perform detailed analysis of the data in support of agency decision making.

* Compare and analyze AHCCCCS coverage and fee-for-service rates to other states.

* Research academic studies to support modeling of program change impacts used in capitation rate setting.

* Conduct ongoing variance analysis of projected impacts of policy changes and actual experience.

* Summarize state and federal regulations

* Contribute to creation of fund sourcing models used in projecting state cost impacts.

* Assist in preparing Access Monitoring Analysis report

* Support for various actuarial and rate setting tasks


Knowledge, Skills & Abilities (KSAs):

* Demonstrated knowledge with Excel, Access and other MS Office applications

* Data analysis and research methods

* Medicaid and managed care payment principles

* Collection, organization, and summary of large data sets using Excel and Access

* Internet research to track rate-setting issues, methodology updates and federal requirements

* Strong ability to work and communicate with a broad spectrum of professionals, and effectively present information both orally and in writing.


Selective Preference(s):

* Computer skills: Cognos Reports and Google Suite.

* Current pursuit of degree in a quantitative field, such as actuarial science, data analytics, math or statistics

* Team and interpersonal skills and Verbal and written communication skills

* Interest in Health Finance and Public Service



At AHCCCS, we promote the importance of work/life balance by offering workplace flexibility and a variety of learning and career development opportunities. Among the many benefits of a career with the State of Arizona, there are 10 paid holidays per year, accrual of sick and annual leave, affordable medical benefits and participation in the Arizona State Retirement Plan.

For a complete list of benefits provided by The State of Arizona, please visit our benefits page

Contact Us:

Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by contacting 602-417-4497.
Requests should be made as early as possible to allow time to arrange the accommodation. Arizona State Government is an AA/EOE/ADA Reasonable Accommodation Employer.


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Medicaid Architect


Dice is the leading career destination for tech experts at every stage of their careers. Our client, Chandra Technologies, Inc., is seeking the following. Apply via Dice today!

Hourly Rate 71 W2 82 CTC1099 Job Description The NC Department of Health and Human Services (DHHS) Information Technology Division (ITD) is seeking Enterprise, Technical and Solutions Architects to perform work associated with the Medicaid Enterprise Systems (MES) project. This person will responsible for the architectural definition, procurement and implementation of highly complex and innovative Medicaid Enterprise Modular solutions. In addition, these roles will participate within an industry best-practice Enterprise Architecture methodology and will oversee the implementation and operation of various vendor-provided technology solutions. This role must be able to collaborate with product-, business- and process owners to evaluate their needs and to translate those needs into highly effective functional and non-functional requirements. This role is responsible for creating several comprehensive technology and information architectures related to various functional business solutions, while providing strategic direction throughout the development process and ensuring that the solution aligns with the Medicaid Enterprise Architecture Modular vision and strategy. In addition, the role will include oversight and compliance with Federal and Statewide Technical Architecture requirements, risk identification and planning. This role requires a person that possesses a strong and diverse background in both traditional and modern business solution- and application architecture concepts, tools and practices. This person must have hands on working knowledge of various platforms including legacy, service oriented and cloud-based solution architectures – Cloud based Architectures are required. Required Knowledge, Skills and Abilities Extensive ability to plan, design and implement complex Medicaid business solution in collaboration with functional solution vendors. Extensive familiarity with architectural evaluation, design and analysis of enterprise wide systems throughout the full implementation life cycle including procurement through operations Extensive hands on experience with overseeing and aligning vendor-based application solutions and architectures to deliver robust system solutions that will align with Medicaid Modular System Integration goals and objectives Extensive familiarity with application programming interfaces and service-oriented design and development to assure seamless integration between various Vendor Functional Modules offered as SaaS or Cloud Hosted Solutions. Ability to identify customer requirements, analyze alternatives and conduct product recommendations related to software, platform and network configurations. Ability to closely collaborate with Enterprise Architecture to ensure functional solutions comply with Enterprise Architecture and CMS 7 Standards and conditions Strong ability to perform as a high functioning architecture team member within a highly flexible and loosely coupled environment, supporting multiple concurrent business-oriented development workstreams. Extensive experience leveraging cloud technologies Strong leadership and guidance on test planning, automation and continuous improvement and deployment processes Superior communication to ensure stakeholders, project managers, developers, and software vendors are aligned with the software development process Extensive business continuity, backup, recovery, high availability and archiving implementation and oversight to ensure vendor solutions align with State expectations. Experience with data integration and data mapping to ensure interoperability between vendor solutions and MES modules Proficiency with the use of Microsoft Word, Excel, PowerPoint, Visio and Project Preferred Knowledge, Skills and Abilities Familiarity with healthcare and healthcare insurance solutions and information architectures, especially Medicaid or similar industry Familiarity with HIPAA rules and regulations Familiarity with CMS certification processes Experience drafting and evaluating RFP’s or other procurement documents Experience working within TOGAF, FEA or other Enterprise Architecture frameworks Required Skills Knowledge of the Medicaid Systems and Solutions (7 years) Knowledge of the MITA Business, Information and Technical architectures (7 years) Extensive familiarity with relational databases as well as other types (Graph Database, NoSQL) and the relative advantages and disadvantages of each (7 years) Extensive familiarity with business intelligence, analytical and reporting tools (7 years) Experience leveraging cloud technologies (5 years) Excellent general IT knowledge (applications development, testing, deployment, operations, documentation, standards, best practices. (7 years) Experience with Technical Proposal Evaluations (7 years) Excellent verbal and written communication skills with the ability present to both technical and business audiences. (7 years) Experience participating or leading projects using an Agile methodology. (7 years) Experience working with various vendors and coordinating with the Systems Integrator (7 years) Preferred Skills Experience with data integration and mapping (5 years) Knowledge on Claims and Financial Processing (5 years) experience in Data Governance, Modelling and Architecture (5 years) Medicaid Architect MITA Business Knowledge, Agile, Technical Proposal Evaluations Higher Competitive Rates will be considered for consultants with advanced skill set Corp to Corp Resumes are welcome Consultants may need a criminal background check


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Humana Louisiana Medicaid CMO, RVP Health Services Job in Metairie, LA


The LA Medicaid CMO, RVP Health Services (CMO) relies on medical background to create and oversee clinical strategy for the region. The CMO requires an in-depth understanding of how organization capabilities interrelate across segments and/or enterprise-wide.


Job Title: Louisiana Medicaid CMO, RVP Health Services

Location: Work from Home in Louisiana Temporarily (Office will be opened in Baton Rouge)

Job Description

The CMO will provide medical leadership and strategy for the Health Services Operations with fiscal responsibility for trend management.

  • Oversee regional utilization management and case management for inpatient cases (acute care hospital, LTAC, Acute rehab, SNF) according to the Humana’s Medicaid policies and procedures.
  • Participate in Quality Operations including chair Quality Management Committee, complete initial peer review on quality of care complaints, complete peer-to-peer written and verbal communications.
  • Oversee administrative budget for regional HSO & Quality Improvement including approve/deny expense reports & requisition requests for department members.
  • Oversee Quality Improvement and HEDIS/STARS metrics improvement with PCP offices and IPAs.
  • Participate in regional level committees and meetings setting medical necessity strategies.
  • Provide oversight and direction for the implementation of regional clinical programs and strategies, as well as, developing and implementing market level strategies.
  • Manage internal operational/functional relationships related to profitability.
  • Assist with network development and provider contracting with various providers and ancillary providers.
  • Serve as clinical liaison with inpatient facilities and joint operating committees to maintain facility relationship and problem solve; especially reviewing contracts as to clinical services.
  • Well-versed on financial aspects of various levels of risk bearing contracts and possess the ability to gain traction and adoption of the providers.
  • Ability to thrive in a highly matrix environment.

Required Qualifications

  • 8 or more years of management experience
  • A current and unrestricted license in Louisiana and willing to obtain licenses, as needed, for various states in region of assignment
  • MD or DO degree
  • Board Certified in an approved ABMS Medical Specialty
  • Excellent communication skills
  • 5 years of established clinical experience
  • Knowledge of the managed care industry including Medicare, Medicaid and or Commercial products
  • Possess analysis and interpretation skills with prior experience leading teams focusing on quality management, utilization management, discharge planning and/or home health or rehab
  • Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

  • Medical management experience, working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.
  • Prior experience within the Louisiana Department of Health
  • Experience working with the Medicaid population or Medicaid Managed Care, PEDS, OB-GYN, Drug Abuse/Addiction, or Behavioral Health
  • Master’s Degree


Scheduled Weekly Hours



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