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Medicaid Eligibility Specialist II (Remote) at Keystone Peer Review

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Medicaid Eligibility Specialist II (Remote)

  • Are you an experienced Medicaid Eligibility Specialist II looking for a new challenge?

  • Do you value care management and quality improvement?
  • Are you motivated, energetic, and excited to become part of the Kepro team?

If so, you might be our next new team member!

Who we need:

The Medicaid Eligibility Specialist II is responsible for supporting the Alabama Medicaid contract by answering incoming telephone calls. Resolving customer questions and complaints and requests. Adhering to internal policies and procedures. Utilizing working knowledge of the organization’s services to meet productivity and quality standards. This is a remote position, open to candidates living anywhere.

Why us?

Kepro is a rapidly growing national quality improvement and care management organization. We work to ensure that over 20 million people receive the right care, at the right time, in the right setting.

People Focused. Mission Driven.

Shape the future of healthcare with us. We are mission driven to improve lives through healthcare quality and clinical expertise.

We do this through our people.

At Kepro, you can do meaningful work that makes a real difference for the lives of individuals across the country. We are an organization that cares deeply about our employees and we provide the training and support to do the best work of your career.

Benefits are a key component of your rewards package at Kepro. These benefits are designed to provide you and your family additional protection, security, and support for both your career and your life away from work. They are comprehensive and fit a variety of needs and situations. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts and more.

What you’ll do:

  • Review the recipient’s completed application and supporting documentation.
  • Perform and document outreach activities for the Agency’s to those in an ABD PHE extension.
  • Make recommendations for the beneficiary ‘s eligibility determination to designated Program staff concerning final disposition.
  • Assist with obtaining and filing initial application for ABD Programs
  • Assist with updating contact information.
  • Refer beneficiaries to Waiver Administering Agencies when appropriate.
  • Secure documentation and verifications needed to determine Medicaid eligibility.
  • Make recommendations to the Agency upon final disposition of applications.


  • Investigates and resolves or reports customer problems. Identifies and escalates difficult situations to the appropriate party.
  • Meets or exceeds standards for call volume and service level per department guidelines.
  • Initiates files by collecting and entering demographic, provider, and procedure information into the system.
  • Serves as liaison between the Call Center Supervisor and Customer Service Representatives.
  • Serves as a subject matter expert for all related processes and customer service workflows.
  • Serves as a mentor/preceptor for new employees during the orientation period.

The list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary from time to time.

What you’ll need:

Required Qualifications

  • Requires High School Diploma or equivalent; (Associates or Bachelor’s Degree in Human Services Field preferred). –
  • Medical terminology course(s) helpful.

Knowledge, Skills, Abilities

  • Knowledge of:

o Medical terminology

o Health insurance industry

  • Ability to:

o Speak English fluently enough to be clearly understood over the telephone.

o Use phone system effectively.

o Research and investigate.

o Follow confidentiality policies and procedures.

o Navigate and use electronic equipment and systems easily and proficiently.

o Multitask on a personal computer while conducting telephone conversations.

o Work in a fast-paced call center environment

o Remain calm and courteous when handling difficult calls and request

  • Skills:

o Effective verbal and listening skills to provide courteous and professional customer service.

o Effective PC skills including electronic mail, intranet and industry standard applications.


  • 2+ year’s customer service/telephone experience in a similar call center environment and/or industry.

Thank You!

We know your time is valuable and we thank you in advance for applying for this position. Due to the high volume of applicants we receive, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Kepro and invite you to apply to future openings that may be of interest. Best of luck in your search!

~ The Kepro Talent Acquisition Team

Mental and Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations will be made as required by law in an attempt to enable an individual with a disability to perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time; key and/or control objects; interact extensively with internal and external customers; occasionally lift and/or move objects weighing up to 10 pounds; and occasionally travel within the state.

EOE AA M/F/Vet/Disability

Kepro is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

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Sr. Investigator, Medicare & Medicaid Job in Atlanta, GA – UnitedHealth Group

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At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us and start doing your life’s best work.SM 

The Sr. Investigator will be responsible for investigating agent/broker complaints across all lines of business in accordance with state and federal regulations.

You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.


  • Conduct confidential compliance investigations related to Agents/Brokers across all lines of business
  • Document all relevant findings in written reports
  • Utilize information from plan members (interviews), agents/brokers, sales operations, claims data, and internal systems
  • Conduct and document interviews (on telephone and in person) for all parties involved in an investigation
  • Report any illegal activities in accordance with all laws and regulations
  • Act as a subject matter expert with identifying and communicating relevant findings to the business
  • Where applicable, provide testimony regarding the investigation
  • Responsible for generating independent work product

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. 

Required Qualifications:

  • High School Diploma/GED (or higher) OR 5+ years of investigative experience
  • 3+ years of investigative experience, preferably within Medicare/Medicaid
  • 2+ years of experience with Local, State & Federal laws and regulations pertaining to health insurance (Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, Affordable Care Act Plans, and/or commercial health insurance)
  • Basic level of proficiency in MS Excel and MS Word 

Preferred Qualifications:

  • Fraud Certification, such as CFE of AHFI
  • Experience directly in Healthcare/Insurance related Compliance, Investigations or Operations
  • Experience with interviewing agents and members
  • Experience within Medicare/Medicaid insurance fraud
  • Experience with investigative data bases  
  • Familiarity with MS Access

Soft Skills:

  • Experience communicating complex information both verbally and in written form
  • Excellent verbal and written communication skills 

Careers with UnitedHealthcare. Work with a Fortune 5 organization that’s serving millions of people as we transform health care with bold ideas. Bring your energy for driving change for the better. Help us improve health access and outcomes for everyone, as we work to advance health equity, connecting people with the care they need to feel their best. As an industry leader, our commitment to improving lives is second to none. 

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy. 

California, Colorado, Connecticut, Nevada, New York, Washington or Rhode Island Residents Only: The salary range for California, Colorado, Connecticut, Nevada, Washington or New York City residents is $56,300 to $110,400.  Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.  

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission. 


Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. 


UnitedHealth Group is a drug – free workplace. Candidates are required to pass a drug test before beginning employment. 



#RPO, #Green

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Medicaid Quality Audits

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Humana Health Horizons in Louisiana is seeking Medicaid Quality Audit Professionals – Behavior Health (BH) to ensure contracted Specialized Behavioral Health Providers adheres to NCQA documentation standards, BH Clinical Practice Guidelines and Louisiana Department of Health’s (LDH)Medicaid contractual requirements. They will travel daily to and from provider offices in their assigned regions to conduct on-site audits, provider education, and collaboration with BH community resources. Each Quality Audit Professional 2 will be assigned to specific regions in the state of Louisiana.


  • Responsible for coordinating on-site or desk top audits with BH providers to include treatment record reviews, member interview and provider education.
  • Utilize departmental tracking tools to request and retrieve treatment record reviews; Store and retrieve records in accordance with established procedures to ensure the timely access of information and records.
  • Conduct ongoing monitoring of treatment records to ensure appropriate utilization of health care resources for members though review and analysis of documentation.
  • Prepares written results of oversight audits by communicating findings, areas of concern and recommendations for improvement, including corrective action requests in accordance with LDH’s strategies.
  • Conducts closing meetings with BH providers to give them a preliminary overview of completed compliance audits.
  • Outreach to members and Providers via telephone or other method of correspondence to assure care needs are being met and all applicable data is received.
  • Follow-up and track Corrective Action Plan responses to ensure implementation.
  • Participate in departmental and company meetings.
  • Document, investigate and resolve formal and informal complaints, quality of care issues, and adverse events.
  • Develop and maintain audit schedules.
  • Train providers on auditing process and develop educational material related to audit errors.
  • Other duties as assigned.

Required Qualifications

  • Must reside in Louisiana’s Medicaid Regions 2, 4, 5 & the southern cities in Region 6 (Click here to view region:
    LA Region Map ).

  • Ability to travel statewide in the state of Louisiana in assigned regions and must be able to cover colleagues in other regions as needed.
  • Unrestricted Licensed Mental Health Practitioner (LMHP) who is licensed to practice independently in Louisiana and is in compliance with the requirements of one of the following regulated areas: Physicians (Psychiatrists), Medical Psychologists, Licensed Psychologists, Licensed Clinical Social Workers (LCSWs), Licensed Professional Counselors (LPCs), Licensed Marriage and Family Therapists (LMFTs), Licensed Addiction Counselors (LACs) or Advanced Practice Registered Nurses (APRN) with specialization in adult psychiatric and mental health.
  • Minimum three (3) years of experience in behavioral health.
  • Must possess strong analytical skills.
  • Strong understanding of HEDIS/CMS/Joint Commission and other national quality measures.  
  • Demonstrated understanding of BH services, BH provider operational processes, and provider’s barriers and challenges to improved quality of care.
  • This role is considered patient facing and is a part of Humana’s Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
  • This role is a 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.

Work at Home Requirements

  • At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.
  • Satellite, cellular and microwave connection can be used only if approved by leadership.
  • Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
  • Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Preferred Qualifications

  • Experience in driving provider level quality improvement initiatives and outcomes to achieve quality targets.
  • Strong understanding of quality improvement culture, behavioral change models.

Additional Information

  • Workstyle: Remote with travel.
  • Travel: Up to 75%  travel statewide in Louisiana in assigned regions and must be able to cover colleagues in other regions as needed.
  • Workdays/Hours: Monday – Friday; 8:00am – 5:00pm CST.
  • Benefits: Benefits are effective on day 1. Full time Associates enjoy competitive pay and a comprehensive benefits package that includes; 401k, Medical, Dental, Vision and a variety of supplemental insurances, tuition assistance and much more…..  
  • Vaccination Statement: Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.
  • Section 1121 of the Louisiana Code of Governmental Ethics states that current or former agency heads or elected officials, board or commission members or public employees of the Louisiana Health Department (LDH) who work directly with LDH’s Medicaid Division cannot be considered for this opportunity. A separation of two (2) or more years from LDH is required for consideration. For more information please visit: Louisiana Board of Ethics (

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.

Social Security Task

Alert: Humana values personal identity protection.  Please be aware that applicants being considered for an interview will be asked to provide a social security number, if it is not already on file.  When required, an email will be sent from with instructions to add the information into the application at Humana’s secure website.  

Scheduled Weekly Hours


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Healthcare Fraud Investigator Lead – Medicare/Medicaid – Remote or Office Based Job at Qlarant

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Qlarant is a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient delivery of health care and human services programs. We have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Qlarant is also a national leader in fighting fraud, waste and abuse for large organizations across the country.  In addition, our Foundation provides grant opportunities to those with programs for under-served communities.

Qlarant has an immediate opening for an Investigator Lead to provide supervision and mentoring to a team of healthcare fraud Investigators.  In addition to your exceptional healthcare fraud investigation knowledge and experience, well qualified candidates will possess prior supervisory and leadership experience.  This position can be home-based in most areas of the U.S. or based in our Los Alamitos, CA office.

As an Investigator Lead working on our Unified Program Integrity Contractor (UPIC) team for the Western Jurisdiction, you can contribute to our efforts to make a positive difference in the future of the Medicare and Medicaid programs.  Our UPIC West team identifies and investigates fraud, waste and abuse in the Medicare and Medicaid programs covering 13 states and 3 territories. 

The Investigator Lead oversees investigations and investigation workload. Independently performs in-depth evaluation and makes field level judgments related to investigations of potential Medicare fraud waste and abuse investigations or cases compliance cases that meet established criteria for referral to the Centers for Medicare & Medicaid for administrative action or to the OIG for criminal action.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

  • Supervises intake investigators and/or investigators and assigns work; regularly reviews team’s leads in screening and/or investigations and actions for quality and appropriateness; monitors workload distribution and timeliness
  • Reviews new investigations and/or incoming leads to determine appropriateness and assigns to investigators; vets providers as required with CMS, law enforcement and supervises vetting process
  • Reviews investigation plans and priority to ensure appropriateness and quality for the specific functions/workload assigned to their team
  • Conducts file reviews regularly of investigations to ensure investigation plan is appropriate and the investigation file documents are entered and summarized within the case tracking systems appropriately
  • Reviews investigator requests for information, data, reports, and correspondence to ensure quality and appropriateness
  • Supervises and conducts investigation actions such as interviewing, onsite investigation, site verification as needed
  • Trains new investigators
  • Leads investigation projects including developing an investigation strategy, conducting meetings with stakeholders, reviewing project actions for quality, and documenting findings in reports for management
  • Utilizes government systems to obtain and analyze provider and beneficiary information
  • Queries Business Objects to run data reports for provider billing information and to analyze for fraud indicators
  • Utilizes CLEAR system to obtain provider information and develop investigation
  • Communicates with the Data and Medical Review departments to ensure efficient investigations
  • Prepares and presents investigations, overpayments, and questions for the weekly CMS meetings
  • Documents investigation information and file reviews (interviews, events, findings, communications, etc.) into the case tracking systems and updates systems as needed
  • Determines investigation appropriateness of fraud, waste and abuse issues in accordance with pre-established criteria
  • Reviews investigative findings with investigators and approves course of action
  • Based on contract requirements, may refer potential adverse decisions to the Manager, Medical Director, or designee
  • Supervises and prepares team’s investigations for the Major Case Coordination meetings and reviews for quality assurance
  • Initiates and maintains communications with law enforcement and appropriate regulatory agencies including presenting or assisting with presenting investigation findings for their consideration to further investigate, prosecute, or seek other appropriate regulatory or administrative remedies
  • Supervises administrative remedies in accordance with major case coordination direction (e.g. payment suspensions, revocations, provider education) and reviews for quality assurance
  • Reviews and approves closing summary of investigation
  • Collect information and documentation as requested by internal and external stakeholders (e.g. CMS, law enforcement, FOIA requests) and submit as required
  • Collaborates with other program integrity contractors as needed
  • Testifies at various legal proceedings as necessary
  • Identifies opportunities to improve processes and procedures
  • Assists Program Integrity Manager and VP of Operations with information and reporting for contract deliverables

Supervisory Responsibilities                                                    

Supervises staff in the operational area.  Carries out supervisory responsibilities in accordance with the organization’s policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

Required Skills

To perform the job successfully, an individual should demonstrate the following competencies:

  • Analytical – Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data.
  • Problem Solving – Gathers and analyses information skillfully; Identifies and resolves problems.
  • Written Communication – Writes clearly and informatively; Able to read and interpret written information.
  • Judgment – Supports and explains reasoning for decisions.

Required Experience


  • A Bachelor’s Degree or four years’ experience in a field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions or equivalent combination of education and experience
  • Three years’ experience fraud investigation/detection (preferred) or in healthcare programs.


  • Certified Fraud Examiner or Accredited Healthcare Anti-Fraud Investigator
  • Prior successful experience with CMS and OIG/FBI or similar agencies
  • Prior superviory experience strongly preferred.

Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.

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Health Equity Director – WV Medicaid

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Position:  Health Equity Director – WV Medicaid Job
This is a remote from home position with occasional visits to the Charleston office. You must be a resident of WV or be willing to relocate.



General business hours, Monday through Friday.



Approximately 25% travel is required throughout the state, and occasional national travel may be required.


This is a very strategic position that is responsible for assisting the state Health Plan community and stakeholder engagement experience, while applying application of science-based quality improvement methods to reduce health disparities.


Primary duties may include, but are not limited to:

• Assist with the strategic design, implementation, and evaluation of health equity efforts in the context of the population health initiatives.

• Inform decision-making around best payer practices related to disparity reductions, including the provision of health equity and social determinant of health resources and research to leadership and programmatic areas.

• Inform decision-making regarding best payer practices related to disparity reductions, including providing Health Plan teams with relevant and applicable resources and research and ensuring that the perspectives of members with disparate outcomes are incorporated into the tailoring of intervention strategies.

• Collaborate with the Health Plan analytics team to ensure the Health Plan collects and meaningfully uses race, ethnicity, and language data to identify disparities.

• Coordinate and collaborate with members, providers, local and state government, community-based organizations, and other entities to impact health disparities at a population level; and ensure that efforts addressed at improving health equity, reducing disparities, and improving cultural competence are designed collaboratively with other entities to have a collective impact for the population.


Required Qualifications

• Requires a BA/BS degree; ination of education and experience, which would provide an equivalent background.

• 5+ years of experience, in public health, social/human services, social work, public policy, health care, education, community development, or justice.




• MPH or higher is strongly preferred.

• A background working in public health is strongly preferred.

• The ability to speak publicly and host a conversation is a must!

• Previous social service experience/Medicaid familiarity is very helpful.

• Previous leadership skills, either as a project manager or people leader, is preferred.

• Ability to work with cross-functional teams is extremely important.

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Medicaid Enterprise Data Architect

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The Information Architecture is responsible for the creation, maintenance and management of IT architectural data models and their lower-level components.

The IA will also be required to interpret, use and apply information contained within MITA Medicaid architecture to inform a range of business improvement activities, particularly those involved in the procurement of IT support systems.

Position is available for extensions.

Minimal Qualifications

Bachelor’s degree in computer science, information systems or related specialty from an accredited college or university AND

Ten years of job specific experience that includes system analysis, design and development, and relationship management.

Minimum Five (5) Years Of Relevant Leadership Experience.

Strong organization skills and comfort level with ambiguity in a fast-paced environment.

Excellent Written, verbal, and diagrammatic communication skills

Demonstrated ability to take initiative and accountability for achieving results.

In depth knowledge and experience with Unified Modeling Language (UML)

Expertise with conceptual, logical and physical data modeling.

Working knowledge of Enterprise Information Architecture concepts and understanding of various database disciplines, including configuration, optimization and performance tuning.

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SME – E&E Team – MS – Medicaid | Datasoft Tech

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Medicaid Eligibility and Enrollment (E&E) Subject
Matter Expert (SME)
About the Job

  • Duration: 3 years w/ possible extension
  • Location: Jackson, Mississippi 
  • Pay rate: Hourly
  • Job ID: 116109



DataSoft Technologies is seeking a SME – E&E Team for our clients in Jackson, MS.


  • 4+ years’ experience with Eligibility systems, tools, and services
  • 3 years of working on IT projects that have critical timelines and deadlines and working with vendors to achieve these milestones as much as possible.
  • Must have ability to adapt and overcome challenges of tight schedules.
  • 2 years’ experience facilitating meetings and discussions with both technical and non-technical staff
  • 1 years’ experience with E&E rules, requirements, and standards, such as the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS), Modified Adjusted Gross Income (MAGI) and non-MAGI Medicaid, Qualified Health Plans, Advance Premium Tax Credit (APTC), etc.
  • 1 years’ experience with technical integration of E&E systems with other payer and trading partner IT systems, including using standards-based Application Programming Interfaces (APIs)



  • 3 years experience working with E&E systems that utilize an Enterprise Service Bus (ESB)
  • 3 years of documenting and reporting project status and risks to management
  • 2 years experience with identity resolution systems, such as a Master Person Index (MPI)
  • Knowledge of other State benefit programs (WIC, SNAP, etc.)


About our Company

DataSoft Technologies is a highly recognized provider of professional IT Consulting services in the US. Founded in 1994, DataSoft Technologies, Inc. provides staff augmentation services for Information Technology and Automotive Services. Our team member benefits include:

  • Paid Holidays/Paid Time Off (PTO)
  • Medical/Dental Insurance
  • Vision Insurance
  • Short Term/Long Term Disability
  • Life Insurance
  • 401 (K)


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Project manager (Healthcare experience – MEDICAID or SNAP/TANF domain must)

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We need experienced Technical Project Managers for ACES (Alabama Combined Eligibility System) implementation. You will be responsible for managing projects to successful completion, ensuring that projects deliver on time, on budget, and in accordance with standards and guidelines over the entire project. You will be managing key projects as part of our client’s strategic business plan. The chosen candidate will need to ensure that changes are delivered to the expectations of stakeholders. experience in candidates should apply as soon as possible! This is a full-time opportunity.
Key responsibilities
– Manage cross functional and technical projects across multiple systems or functions
– Produce and execute on complex project plans and key milestones
– Assign the right people with the right skills at the right time
– Proactively identify and mitigate risks
– Understand and manage project interdependencies
– Arrange project priorities with strategies/objectives


– Background working with PMP Certification
– Experience managing projects and implementation in a retail/merchandising environment
– Good Understanding of MEDICAID or SNAP/TANF domain – Must
– Practical knowledge of Deliverable
– Comprehensive knowledge of Cloud Technologies
– Experience with gap analysis
– Applicants should have proficiency using commonly accepted scheduling and project management tools
– Creative problem solver who anticipates risks and opportunities and maintains a vision for continuous improvement
– Can work independently with minimal supervision
– Ability to understand and communicate technical concepts to both technical and non-technical colleagues
– Excellent communication skills (written and verbal)
– You could be a good applicant for this position if you are flexible and focused
– Demonstrated flexibility to adapt to changes in procedures
– Minimum of 10+ years of relevant Project Management experience
– Experience working with e-learning and blended learning programs
– Commitment and abilities to meet critical business deadlines

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Senior Business Analyst – Medicaid (Gainwell)

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Be part of a team that unleashes the power of leading-edge technologies to help improve the health and well-being of those most vulnerable in our country and communities. Working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work flexibility, learning, and career development. You’ll add to your technical credentials and certifications while enjoying a generous, flexible vacation policy and educational assistance. We also have comprehensive leadership and technical development academies to help build your skills and capabilities.



As a Senior Business Analyst – Medicaid at Gainwell, you can contribute your skills as we harness the power of technology to help our clients improve the health and well-being of the members they serve — a community’s most vulnerable. Connect your passion with purpose, teaming with people who thrive on finding innovative solutions to some of healthcare’s biggest challenges. Here are the details on this position.

Your role in our mission

Play a critical part in ensuring Gainwell is meeting our clients’ objectives in important areas.

  • Provide business solutions, process improvements, business case and change consulting to the external client at functional and senior management level. The business domain includes Healthcare business processes, specifically focused on Medicaid and Medicare and CMS.
  • Help the client innovate and formulate business solutions and technology enabled business models to implement CMS mandated or State directed initiatives.
  • Analyze and document current business processes and determine new processes to solve complex Healthcare initiatives.
  • Document requirements for business and system requirements.
  • Interface with the technical team to ensure designs are understood and properly implemented.
  • Verify solution meets the defined requirements through scenario testing.
  • Work as a liaison between the customer and the technical team to provide quality solutions for the customer’s needs.

What we’re looking for

  • 6+ years of associated work experience in a software development environment
  • Practical ability with Microsoft Office as well as SQL
  • Demonstrated ability to independently manage multiple responsibilities, prioritize tasks and meet deadlines
  • Excellent written and verbal communication
  • Ability to perform in lead Business Analyst role on projects

What you should expect in this role

  • Onsite, remote and hybrid opportunities
  • Position open to candidates residing in Arkansas, El Paso, TX or Puerto Rico



The pay range for this position is $63,100.00 – $90,200.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.


We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.


Gainwell Technologies is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.

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Senior Manager, Network Management / Medicaid (remote) – CVS

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Job ID: 2352687BR

Category: Contract Administration

Remote: Fully Remote

Job Description
The Senior Manager, in this individual contributor role, will manage the development of contracts and agreements with providers and delivery systems in conjunction with being accountable for designing conceptual models, initiative planning, and negotiating high value/risk contracts with the most complex and challenging, market/region/national, largest group/system or highest value/volume of spend providers in accordance with company standards in order to maintain and enhance provider networks, while working cross functionally to ensure consistency with all contracting strategies and meeting and exceeding accessibility, quality, compliance, and financial goals and cost initiatives.

Roles and Responsibilities:

• Negotiates and executes, conducts high level review and analysis, dispute resolution and/or settlement negotiations of contracts with larger and more complex, market-based, group/system providers.
• Responsible for contract performance (aggressively manage contract operating costs, optimize performance of quality and productivity) and supports the development and implementation of value-based contract relationships in support of business strategies.
• Recruits providers as needed to ensure attainment of network expansion and adequacy targets.
• Accountable for actively managing financial cost performance using key business indicators, metrics and analysis/planning tools.
• Collaborates cross-functionally to manage provider compensation and pricing development activities, submission of contractual information, and the review and analysis of reports as part of negotiation and reimbursement modeling activities.
• Responsible for identifying and managing cost issues and initiating appropriate cost saving initiatives and/or settlement activities.
• Assists with the design, development, management, and or implementation of strategic network configurations and integration activities.
• Drives or guides development of holistic solutions or strategic plans negotiates and executes contracts with the most complex, market /region/national, largest group/system or highest value/volume of spend providers with significant financial implications.
• Recruits providers as needed to ensure attainment of network expansion and adequacy targets.
• Accountable for cost arrangements within defined groups.
• Collaborates cross-functionally to manage provider compensation and pricing development activities, submission of contractual information, and the review and analysis of reports as part of negotiation and reimbursement modeling activities.
• Responsible for identifying and managing cost issues and collaborating cross functionally to execute significant cost saving initiatives.
• Represents company with high visibility constituents, including customers and community groups. Promotes collaboration with internal partners.
• Evaluates, helps formulate, and implements the provider network strategic plans to achieve contracting targets and manage medical costs through effective provider contracting to meet state contract and product requirements.
• Collaborates with internal partners to assess effectiveness of tactical plan in managing costs.
• May optimize interaction with assigned providers and internal business partners to facilitate relationships and ensure provider needs are met.
• Ensures resolution of escalated issues related to contract interpretation and parameters.
• Interprets contractual requirements including federal and state regulations and NCQA.
• Participates in JOC meetings.
• Promotes and educate providers on cultural competency.
• Sets specific, challenging and achievable objectives and action plans.
• Manages complex, contractual relationships with providers according to prescribed guidelines in support of national and regional network strategies.
• Mentor and coach new/more junior staff to educate and inform on accreditation and regulatory standards as well as policies on credentialing and re-credentialing.

Pay Range
The typical pay range for this role is:
Minimum: 75,400
Maximum: 162,700

Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.

Required Qualifications
Experience with Medicaid Managed Care

Proven working knowledge of provider financial issues and competitor strategies, complex contracting options, financial/contracting arrangements and regulatory requirements

7+ years related experience and expert level negotiation skills with successful track record negotiating contracts with large or complex provider systems

Ability to travel up to 20% of time in assigned region.

Preferred Qualifications
Strong communication, critical thinking, problem resolution and interpersonal skills

Knowledge and experience with managed care landscape in Michigan, Illinois, Kansas

Preferred Locations: Michigan, Illinois, Kansas

Bachelor’s Degree or equivalent combination of education and experience.

Business Overview
Bring your heart to CVS Health Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law. 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.