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Care Manager (RN (Medicaid) Job in New York, NY at MetroPlus Health Plan

 
 

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MetroPlus Health PlanNew York, NY Full-time

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  • About NYC Health + Hospitals
  • MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc.
  • As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics.
  • For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
  • The primary goal of the Care Manager is to optimize members’ health care and delivery of care experience with expected cost savings due to improved quality of care.
  • This is accomplished through engagement and understanding of the member’s needs, environment, providers, support system and optimization of services available to them.
  • Care Manager is expected to assess and evaluate member’s needs, be a creative, efficient and resourceful problem solver.
  • In collaboration with the members’ care team, a plan of care with individualized goals and interventions is developed, implemented and outcomes evaluated.
  • Address member’s problems and needs: clinical, psychosocial, financial, environmental
  • Provide services to members of varying age, risk level, clinical scenario, culture, financial means, social support, and motivation
  • Engage members in a collaborative relationship, empowering them to self-manage their physical, psychosocial and environmental health to improve and maintain lifelong well being
  • Prepare member-oriented plan of care with member, caregivers, and health care providers, integrating concepts of cultural sensitivity and privacy practices
  • Participate in interdisciplinary rounds
  • Ensure plans of care have individualized goals and interventions
  • Communicate plan of care to Primary Care Physician
  • Address gaps in care with the member and provider
  • Address members social determinants of health issues
  • Link members to available resources
  • Provide care management support during Transitions of Care
  • Ensure member/caregiver understanding as it relates to language barriers, stress reaction or cognitive limitations/barriers
  • Train member on relevant chronic diseases, preventive care, medication management (medication reconciliation and adherence), home safety, etc.
  • Provide Complex care management including but not limited to; ensuring access to care, reducing unnecessary hospitalizations, and appropriately referring to community supports
  • Advocate for members by assisting them to address challenges and make informed choices regarding clinical status and treatment options
  • Employ critical thinking and judgment when dealing with unplanned issues
  • Maintain knowledge of Chronic Conditions and use job aids as a guidance
  • Maintain accurate, comprehensive and current clinical and non-clinical documentation in DCMS, the Care Management System
  • Comply with all orientation requirements, annual and other mandatory trainings, organizational and departmental policies and procedures, and actively participate in evaluation process
  • Maintain professional competencies as a Care Manager
  • Other duties as assigned by Manager
  • Background: Registered Nurse, Bachelor’s Degree in Nursing required
  • An equivalent combination of training, educational background, and experience in related fields such as hospital, home care, ambulatory setting and educational disciplines.
  • Prior experience in Care Management in a health care and/or Managed Care setting preferred
  • Proficiency with computers navigating in multiple systems and web- based applications
  • Confident, autonomous, solution driven, detail oriented, high standards of excellence, nonjudgmental, diplomatic, resourceful, intuitive, dedicated, resilient and proactive
  • Strong verbal and written communication skills including motivational coaching, influencing and negotiation abilities
  • Time management and organizational skills
  • Strong problem-solving skills
  • Ability to prioritize and manage changing priorities under pressure
  • Must know how to use Microsoft Office applications including Word, Excel, and PowerPoint and Outlook.
  • Ability to proficiently read and interpret medical records, claims data, pharmacy, lab reports and prescriptions required
  • If needed, ability to travel within the MetroPlus service area to participate in facility visits, community events, home visits or other community meetings, including conferences.
  • Registered Nurse or LMSW/LCSW with current NYS license

 
 

Clipped from: https://jobsearcher.com/j/care-manager-rn-medicaid-at-metroplus-health-plan-in-new-york-ny-RGPm2Rj?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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Health Net of California Training & Development Specialist III-Medicaid Job in Sacramento, CA

 
 

You could be the one who changes everything for our 25 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, multi-national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.

Position Purpose:

The Training and Development Specialist III is responsible for the design and training of educationally based documentation, curricula, training tools and information that enhance employee commitment, motivation, operational improvement, job performance and overall service to associates or customers.
Additionally, may participate in workflow task and performance issue analysis and consultation to identify methods to improve performance/organizational effectiveness; implement performance based solutions and quick response tools; gap analysis to assess individual performance against department standards; conduct system testing with IT prior to new application rollout.

  • Analyzes, designs, develops, delivers and evaluates curricula, materials, training tools and information to maximize associate effectiveness, improving organizational performance and service to multiple customers.
  • Serves as project lead to develop, deliver, and implement training and performance support systems associated with large scale projects.
  • Identifies additional training solutions that enhance staff development and performance.
  • Provides consultation and support to department on workflow analysis, performance improvement methods, develop and recommend improvements and innovations to business operation.
  • Serves on system implementation and other cross-functional project teams to ensure rollout of new system applications by analyzing requirements, translating into effective training tools, delivering training, troubleshooting and evaluating issues prior and during production integration.
  • Explore/research distance learning and training strategies through training publications, professional organizations, and Internet to continuously improve training project quality.
  • May be required to travel per business needs, up to 10%

Our Comprehensive Benefits Package:

  • Flexible work solutions including remote options, hybrid work schedules and dress flexibility
  • Competitive pay
  • Paid Time Off including paid holidays
  • Health insurance coverage for you and dependents
  • 401(k) and stock purchase plans
  • Tuition reimbursement and best-in-class training and development
Education/Experience:
  • Bachelor’s Degree in Education or related field, or equivalent combination of education/experience.
  • Master’s Degree in Instructional Technology preferred.
  • Broad technical, professional or administrative training experience required.
  • 3 years’ work-related experience; experience in curriculum design and development for adult audience.
License/Certification:

None required; Training and development professional development certification preferred.

***This position will be required to work in the local office once work from home orders have been lifted.


Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

 
 

Clipped from: https://www.glassdoor.com/job-listing/training-and-development-specialist-iii-medicaid-centene-JV_IC1147229_KO0,48_KE49,56.htm?jl=1007562898452&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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AmeriHealth Caritas Jobs – Director Medicaid Markets Solutions in Newtown Square, Pennsylvania

 
 

Director Medicaid Markets Solutions

Location: Newtown Square, PA

Primary Job Function: Medical Management

ID**: 23186

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 .

Responsibilities:

Reporting to the EVP Medicaid Markets, the Dir Medicaid Markets Solutions monitors and contributes to special/strategic projects as designated by the EVP and/or CEO. These projects are strategic in nature, highly complex, and may involve overseeing a cross functional team to ensure successful project completion. They involve applications that are key to the overall performance, financial and operational, of the all existing and growth Medicaid products. Additional responsibilities include:

  • Assists the Medicaid Markets organization with the design, planning and implementation of major regulatory, functional initiatives
  • Collaborate with AmeriHealth shared services, key stakeholders and the Enterprise Optimization Office on all designated projects
  • Provides regular reporting on projects, key metrics, open issues and barriers to completion
  • Organizes, problem solves, raises issues, and integrates initiatives on behalf of the EVP and Medicaid Market executive leadership.
  • Acts as a liaison to operating entity and staff group organizations to resolve problems and ensure successful implementation of functional initiatives and related projects

Education/Experience:

  • Bachelor’s Degree. Master’s Degree preferred Health Care, Business Administration, Operations Management or related field.
  • 3-5 years Managed Care experience.
  • 5-10 years finance and/or project management experience.
  • Critical thinker, strong business acumen, Multi-tasker, Ability to influence decisions.

EOE Minorities/Females/Protected Veterans/Disabled

 
 

Clipped from: https://amerihealthcaritas.dejobs.org/newtown-square-pa/director-medicaid-markets-solutions/CBE799B088714FFC813C34EF0B10B145/job/?utm_source=.JOBS+XML+Feed-DE&utm_medium=.JOBS+Universe&utm_campaign=.JOBS+XML+Feed&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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Carefirst Blue Cross Blue Shield Supervisor, Workforce Management (MD Medicaid)

 
 

Resp & Qualifications

PURPOSE:
The Supervisor, Workforce Management (WFM) is responsible for executing workforce management processes across the Customer Service Center network to ensure efficient utilization of resources to meet service level objectives. This includes adherence of standardized workforce management practices, policies and procedures, and overseeing the maintenance of the workforce management system. The WFM Supervisor develops and coaches the Workforce Management team.


ESSENTIAL FUNCTIONS:

  • Supervises, coaches and develops by accurately assessing strengths and development needs of employees, giving timely and specific feedback, as well as challenges direct reports to optimize performance.

 
 

  • Execution of the business strategy and overall design of the Customer Service Center organization. Provides reports and analysis to Customer Service Center leadership to assist in making informed business decisions.

 
 

  • Create and maintain a quality work environment that motivates team members to perform at their highest levels and affects positive employee and business partner relationships. Creates a desire to excel by recognizing, rewarding, training and informing.

 
 

  • Suggests and influences process changes for the Workforce Management Analyst role.

 
 

  • Ensure that each direct report is effectively communicating with their respective business partners continuously.

 
 

  • Participate in and support Continuous Improvement activities that are scalable through the Customer Service center organization. Creates Standard Work documentation for the Workforce team to align on consistent processes.

SUPERVISORY RESPONSIBILITY:
This position manages people – 5-10

QUALIFICATIONS:


Education Level: Bachelor’s Degree. In lieu of a Bachelor’s degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Experience: 3 years experience in service center operations or Scheduling/Forecasting within a Call Center environment. Demonstrated leadership skills

Knowledge, Skills and Abilities (KSAs)

  • Must be able to provide clear and concise direction in a rapidly changing environment
  • Strong sense of customer service
  • Strong analytical and quantitative aptitude
  • Microsoft Office
  • 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.

 
 

Department

Department: MD Medicaid- Member 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: www.carefirst.com/careers

Closing Date

Please apply before: 2/10/2022

Federal Disc/Physical Demand

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

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle 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

 
 

Clipped from: https://www.glassdoor.com/job-listing/supervisor-workforce-management-md-medicaid-carefirst-bluecross-blueshield-JV_IC1153614_KO0,43_KE44,74.htm?jl=1007562898489&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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Atrius Health Program Manager, ACO Medicaid Job in Newton, MA

 
 

Atrius Health is a nonprofit healthcare leader delivering a system of connected care that enables us to know our patients better so that we can serve them well. Across 32 clinical locations, more than 50 specialties and 825 physicians, we provide proactive, customized care to more than 720,000 adult and pediatric patients across eastern Massachusetts.

The Atrius Health practices including Dedham Medical Associates, Granite Medical Group, Harvard Vanguard Medical Associates and PMG Physician Associates – together with VNA Care – work in collaboration with hospital partners, community specialists and skilled nursing facilities, to develop innovative and effective ways of delivering care in the most appropriate setting, making it easier for patients to be healthy.

We believe that by establishing a solid foundation of knowledge, understanding and trust with each of our patients, we enrich their health and enhance their lives.

 
 

SUMMARY

Under general direction, the ACO Program Manager leads the planning, direction, and coordination for Medicare, the assigned ACO product line. Supports director in developing overall ACO strategy. Responsible for implementation, relationship management, monitoring and compliance and policy for assigned area. In collaboration with the Director and with ACO Medical Director, supports ACO performance management, identifying opportunities for improvement. Closely collaborates with clinical operations, population health services, quality, information systems, analytics, finance, legal, and compliance. Develops and executes ACO implementation plan, ensuring strong performance and timely deliverable completion. Provides oversight and monitoring for compliance with all contractual and regulatory requirements of assigned ACO. Partners with the Director to evaluate prospective models and make participation recommendations. By ensuring sound business decisions, program implementation, and performance management, the ACO Program Manager supports transformation of care to improve lives at Atrius Health.

EDUCATION/LICENSES/CERTIFICATIONS

Bachelor’s degree required. Master’s degree (or equivalent) in business, public health or health administration preferred.

EXPERIENCE

Minimum of 5 years of progressive experience in fields such as managed care, population health, or performance improvement, planning, or business. Background in healthcare preferred. Medicare ACO or Medicaid ACO experience preferred.

 
 

SKILLS

Excellent verbal and written communication skills with proven ability to communicate effectively with a large and diverse constituency, in verbal, written, and presentation formats. Ability to work with a high degree of independence in a dynamic environment. Strong analytic and problem-solving skills. Skills in managing small to medium projects. Excellent attention to detail, with high degree of independence and good judgment. Strong interpersonal skills, experience managing through influence, fostering a collaborative work environment. Treat others with kindness and compassion every day.

Atrius Health is committed to a policy of non-discrimination and equal employment opportunity. All patients, employees, applicants, and other constituents of Atrius Health will be treated with respect and dignity regardless of race, national origin, gender, age, religion, disability, veteran status, marital/domestic partner status, parental status, sexual orientation and gender identity and/or expression, or other dimensions of diversity.

 
 

Benefits Include:

  • Up to 8% company retirement contribution,

 
 

  • Generous Paid Time Off

 
 

  • 10 paid holidays,

 
 

  • Paid professional development,

 
 

  • Generous health and welfare benefit package.

Clipped from: https://www.glassdoor.com/job-listing/program-manager-aco-medicaid-atrius-health-JV_IC1154636_KO0,28_KE29,42.htm?jl=1007562837924&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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Medicaid Acquisition Integration Lead(Acquisition Integration Advisor) – Remote

 
 

**Description**

The Medicaid Acquisition Integration Lead (Acquisition Integration Advisor) performs project-oriented duties related to the integration of an acquired entity into the company. The Medicaid Acquisition Integration Lead (Acquisition Integration Advisor) works on problems of diverse scope and complexity ranging from moderate to substantial.



**Responsibilities**

The Medicaid Acquisition Integration Lead (Acquisition Integration Advisor) implements activities and projects associated with the assimilation of practices and systems where the primary competence is in project management and integration related disciplines. This role will partner with stakeholders across the organization after the merger/acquisition decision has been reached with a focus on integration activities.


Primary Responsibilities include:


+ Advises executives to develop functional strategies (often segment specific) on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision.



+ Uses independent judgment requiring analysis of variable factors and determining the best course of action.


+ Develops and manage all aspects of project and program engagement from planning, external vendor relationships, communications, resources, budget, change, risks and issues


+ Manages the full project life cycle, including review of various sources to assess requirements, creation of project plans and schedules, obtaining and managing resources, managing budget, and facilitating project execution, deployment and closure.


+ Plans, organizes, monitors, and oversees integration utilizing cross functional teams to deliver defined requirements and meet company strategic objectives.


+ Creates and/or supports the blueprinting process and helps business areas complete deliverables.


+ Understands interdependencies between technology, operations and business needs. Provides functional and technical knowledge across multiple business and technical areas.


+ Defines the Statement of Work and Specifications for the requested goods and services.


+ Supports the overall integration by leading dedicated work streams. Identify and develop contingency plans to mitigate and address risks and procures adequate resources to achieve project objectives in planned timeframes. Provides status reporting regarding project milestones, deliverable, dependencies, risks and issues, communicating across.


+ Actively demonstrates Humana core values in all interactions


+ Actively seeks growth and development opportunities provided within the company and without, committing to constant growth and evolution as a professional and for the Humana Medicaid team.


+ Must be passionate about contributing to an organization focused on continuously improving consumer experiences.

**Required Qualifications**


+ Bachelor’s Degree or equivalent experience.



+ Five (5) or more years of technical and/or business project management experience.


+ Two (2) or more years System and/or business integration experience.


+ Knowledge of Systems Development Life Cycle, Waterfall, and Agile Development Methodologies.


+ Possess a solid understanding of operations, technology, communications and processes


+ Must have a room in your home designated as a home office; away from high traffic areas where confidential information may be secured.


+ Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10×1 (10mbs download x 1mbs upload) is required.


+ For this job, associates are required to be fully COVID vaccinated or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are a healthcare company committed to putting health and safety first for our members, patients, associates, and the communities we serve.


+ If progressed to offer, you will be required to: Provide proof of full vaccination **OR** Commit to weekly testing, following all CDC protocols, **OR** Provide documentation for a medical or religious exemption consideration. This policy will not supersede state or local laws. Requests for these exemptions should be submitted at least 2 weeks prior to your scheduled first day of work.

**Preferred Qualifications**


+ Two (2) or more years of leadership experience.



+ Two (3) or more years of experience in Health Plan Operations and/or Healthcare IT systems.


+ Two (2) or more years previous experience working in Mergers and Acquisition field.


+ Experience working with Medicaid and/or Medicare Plans.


+ Proficiency in Microsoft Office programs.


+ Possess a solid understanding of operations, technology, communications and processes.


+ Six Sigma and / or Project Management Institute certification.

**Additional Information**


Travel: **Up to 30% to various states.**


Work Hours: **Eastern Standard Time or Central Standard Time.**


**Interview Format**


As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.


If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview.  If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.


If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided.  Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.


**Scheduled Weekly Hours**


40

 

Clipped from: https://www.mendeley.com/careers/job/medicaid-acquisition-integration-leadacquisition-integration-advisor-remote-us-7260220?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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Carefirst Blue Cross Blue Shield Care Management Coordinator (MD Medicaid) Job in Owings Mills, MD

 
 

Resp & Qualifications

PURPOSE:
Supports Care Management clinical teams by assisting with non-clinical administrative tasks and responsibilities related to care coordination and quality of care.


ESSENTIAL FUNCTIONS:

  • Assists with member follow up and coordination of care that does not require intervention from a clinician (post discharge or post graduation monitoring; finding appointments; arranging services, etc), enabling clinicians to perform at the top of their license.

 
 

  • Screens, and/or prioritizes members using targeted intervention business rules and processes to identify needed services. Transitions to appropriate clinical resources/programs as necessary.
  • Provides general support and coordination services for the department including but not limited to answering telephone calls, taking messages, letters and correspondence, researching information and assisting in solving problems.

 
 

  • Performs member or provider related administrative support which may include benefit verification, authorization management and case documentation.

 
 

  • Assists with reporting, data tracking, gathering, organization and dissemination of information

QUALIFICATIONS:
Education Level: High School Diploma


Experience: 3 years experience in health care claims/service areas or office support.


Preferred Qualifications:Two years’ experience in health care/managed care setting or previous work experience within division


Knowledge, Skills and Abilities (KSAs)

  • Ability to effectively participate in a multi-disciplinary team including internal and external participants
  • Excellent communication, organizational and customer service skills
  • Knowledge of basic medical terminology and concepts used in care management
  • Knowledge of standardized processes and procedures for evaluating medical support operations business practices
  • Excellent independent judgment and decision-making skills, consistently demonstrating tact and diplomacy
  • Ability to pay attention to the minute details of a project or task
  • Advanced knowledge in the use of web-based technology and Microsoft Office applications such as Word, Excel, and Power Point
  • 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.

Department

Department: Maryland Medcaid Case Management

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: www.carefirst.com/careers

Closing Date

Please apply before: 2/9/2022

Federal Disc/Physical Demand

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

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle 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

 
 

Clipped from: https://www.glassdoor.com/job-listing/care-management-coordinator-md-medicaid-carefirst-bluecross-blueshield-JV_IC1153614_KO0,39_KE40,70.htm?jl=1007562898065&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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Market Development Advisor – Louisiana Medicaid

 
 

Humana Healthy Horizons is seeking a Market Development Advisor who will work side-by-side with the Medicaid COO and team to ensure that the health plan is meeting or exceeding corporate Medicaid performance benchmarks and contractual obligations. Helps advise executives in developing functional strategies on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision, Uses independent judgment requiring analysis of variable factors and determining the best course of action.

Responsibilities

The Market Advisor develops strategy for project planning and facilitates coordination and communication between owners and other teams responsible for execution and production.

  • Collaborates with cross functional teams across the Enterprise, including Member and Provider Call Center, Claims, Clinical, Provider Relations, Network Operations, etc.
  • Operates as a problem solver, highly self-motivated, organized, detail-oriented, and will exhibit a high level of initiative.
  • Serves as an essential member of the Market Operations team leading multiple projects of varying levels of complexity.
  • Collaborates with executive leaders on risk mitigation objectives and operational enhancements.
  • Communicates responsibilities, assignments, and deliverables to teams, and at key points throughout projects.
  • Coordinates and leads meetings with stakeholders to ensure accountability and timely delivery of Market Operations campaigns and project outcomes.
  • Drives planning and implementation of operational process improvement activities for various functional areas.
  • Develops plans of action to prevent delays in projects and/or the department’s workflow.

Required Qualifications

  • Bachelor’s Degree.
  • Minimum two (2) years with health plan operations experience, preferably Louisiana Medicaid Manage Care.
  • Minimum three to five (3-5) years managing large scale, strategic projects and cross functional teams.
  • Must reside in the state of Louisiana.
  • Process and continuous improvement experience.
  • Proven ability to develop working relationships within a highly matrixed business environment.
  • Strong interpersonal skills resulting in exceptional rapport with people.
  • Ability to analyze data and make informed recommendations.
  • Proficiency in Microsoft applications including PowerPoint and Access.
  • Advanced proficiency in Excel specifically creating and using pivot tables for reports of large data sets.
  • Experience using Visio and/or MS Project to develop and manage project plans.
  • Ability to manage multiple competing priorities in a fast paced environment.
  • Excellent verbal and written communication skills.
  • This role is part of Humana’s Driver safety program and therefore requires an individual to have a valid state driver’s license and proof of personal vehicle liability insurance with at least 100,000/300,000/100,000 limits.
  • Must have a room in your home designated as a home office; away from high traffic areas where confidential information may be secured.
  • Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10×1 (10mbs download x 1mbs upload) is required.
  • For this job, associates are required to be fully COVID vaccinated or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are a healthcare company committed to putting health and safety first for our members, patients, associates, and the communities we serve.
  • If progressed to offer, you will be required to: Provide proof of full vaccination OR Commit to weekly testing, following all CDC protocols, OR Provide documentation for a medical or religious exemption consideration. This policy will not supersede state or local laws. Requests for these exemptions should be submitted at least 2 weeks prior to your scheduled first day of work.

Preferred Qualifications

  • Master’s Degree
  • Six Sigma and / or Project Management Institute certification.
  • Experience working in Louisiana Medicaid Managed Care.

Additional Information

  • Work Style: Remote currently but Hybrid Office in the future in one of two office locations. The office locations are in Baton Rouge and Metairie, Louisiana. The Hybrid Office schedule is typically 3 – 4 days per week and the remaining work days of the week will be remote. Office schedule frequency will be determined by leadership.
  • Travel: up to 50%.

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Scheduled Weekly Hours

40

 
 

Clipped from: https://www.indeed.com/viewjob?jk=d84eaa145389bbc0&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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Louisiana Medicaid CMO, RVP Health Services

 
 

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.

Responsibilities

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

#PhysicianCareers

Scheduled Weekly Hours

40

 
 

Clipped from: https://www.indeed.com/viewjob?jk=b952832854ae72fe&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Posted on

Medicaid State Operations Analyst – Tampa

 
 

Description

SHIFT: Day Job


SCHEDULE: Full-time


Responsible for researching, analyzing, documenting and coordinating the resolution of escalated and/or complex claims issues for the Health Plan and requires expert knowledge of all systems, tools and processes.


Primary duties may include, but are not limited to:


+ Receiving and responding to state or federal regulatory complaints related to claims


+ Managing health plan dispute escalations


+ Quality review of various dispute outcomes


+ Managing complex system issues


+ Managing state updates


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. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s 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.


Qualifications


Requirements:


+ BA/BS degree


+ Minimum of 5 years of claims research and/or issue resolution or analysis of reimbursement methodologies within the health care industry


+ Or any combination of education and experience which would provide an equivalent background


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. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s 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: PS59557-Florida

 
 

Clipped from: https://www.mendeley.com/careers/job/medicaid-state-operations-analyst-7894555?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic