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American Institutes for ResearchRockville, MD

• AIRs Payer Innovation, Transformation, and Support program area is seeking a Researcher with a strong background in Medicare and Medicaid policy to join AIRs Health Division.
  
• The Researcher will support projects ranging from technical assistance and implementation support to evaluation and analytical support for CMS, states, and foundations.
  
• Candidates hired for the position might initially start working remotely but will eventually have the option to work from one of our offices located in Arlington, VA; Rockville, MD; Austin, TX; Chicago, IL; Chapel Hill, NC or Waltham, MA or continue to work remotely.
  
• Established in 1946, with headquarters in Arlington, Virginia, AIR is a nonpartisan, not-for-profit institution that conducts behavioral and social science research and delivers technical assistance to solve some of the most urgent challenges in the U.S. and around the world.
  
• We advance evidence in the areas of education, health, the workforce, human services, and international development to create a better, more equitable world.
  
• AIRs commitment to diversity goes beyond legal compliance to its full integration in our strategy, operations, and work environment.
  
• At AIR, we define diversity broadly, considering everyones unique life and community experiences.
  
• We believe that embracing diverse perspectives, abilities/disabilities, racial/ethnic and cultural backgrounds, styles, ages, genders, gender identities and expressions, education backgrounds, and life stories drives innovation and employee engagement.
  
• Learn more about AIR’s Diversity, Equity, and Inclusion Strategy and hear from our staff by clicking here.
  
• Provide research and analytical support and task-level leadership for major contract and grant research, implementation, technical assistance, and evaluation projects.
  
• Support project teams in developing and carrying out the work, manage small teams under the leadership of Senior and Principal Researchers to ensure the timely completion of all deliverables within budget, and with high quality research standards that meet client requirements.
  
• This position will require collaboration within and outside AIR, including with program providers, subject matter experts, as well as federal, state, and local agency officials.
  
• Masters degree in health administration, MPP, MBA or MPA (with health-related focus/concentrations) with 4+ years of experience in a similar contracted research/consulting firm, Federal or State-level government, or foundation that conducts policy and health services research, or PhD in public policy, economics, psychology, sociology, anthropology, other social science discipline.
  
• At least 2 years of experience working on Medicaid-related research.
  
• Some experience with research on either Medicare or state-based health exchanges is preferred but not required.
  
• AIR is seeking a Researcher who values diversity, equity, and inclusion.
  
• Comfortable working in a virtual/dispersed work environment.
  
• AIR requires all new hires to be fully vaccinated against COVID-19 or receive a legally required exemption from AIR, as a condition of employment.
  
• AIR will ask candidates to verify their vaccination status only after a conditional offer of employment is made.
  
• Applicants should not provide information about their vaccination status or need for exemption prior to receiving a conditional offer of employment from AIR
  
• Applicants must be currently authorized to work in the U.S. on a full-time basis.
  
• Employment-based visa sponsorship (including H-1B sponsorship) is not available for this position.
  
• Depending on project work, qualified candidates may need to meet certain residency requirements.
  
• All qualified applicants will receive consideration for employment without discrimination on the basis of age, race, color, religion, sex, gender, gender identity/expression, sexual orientation, national origin, protected veteran status, or disability.
  
• AIR adheres to strict child safeguarding principles.
  
• All selected candidates will be expected to adhere to these standards and principles and will therefore undergo rigorous reference and background checks.
  

Stand out and contact American Institutes for Research directly

Updated 3 days ago

Clipped from: https://www.linkedin.com/jobs/view/senior-manager-medicaid-operations-at-conduent-3221341749/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Through our dedicated associates, Conduent delivers mission-critical services and solutions on behalf of Fortune 100 companies and over 500 governments – creating exceptional outcomes for our clients and the millions of people who count on them.


You have an opportunity to personally thrive, make a difference and be part of a culture where individuality is noticed and valued every day.


Senior Manager, Medicaid Operaions


Summary


The Senior Manager, Service Delivery leads the Operations and IT Service Delivery teams as the point of contact

• Directs the efforts of four major operational areas (call center, mail center, provider relations and drug rebate) for Pharmacy Benefits Management administered by the state’s Medicaid department
  
• Liaise between state and technical development/support teams for release management efforts and delivery escalations
  
• Provide leadership for day-to-day operational delivery for onsite & remote resources
  
• Lead service delivery experience to the customer by being the single point of ownership and accountable
  
• Establish and maintain customer relationships
  
• Set a vision, strategy, and execution plan for team members
  
  
  

Qualifications


Education: Bachelor’s degree in a related field


Experience: 10 years Operations Leadership including Contact Center Ops


2+ years Project Management experience (PMP preferred)


Pharmacy Benefits Management (PBM) Experience Pref


Proficiency with Microsoft Office suite


Excellent communications and interpersonal skills


Conduent is an Equal Opportunity Employer and considers applicants for all positions without regard to race, color, creed, religion, ancestry, national origin, age, gender identity, gender expression, sex/gender, marital status, sexual orientation, physical or mental disability, medical condition, use of a guide dog or service animal, military/veteran status, citizenship status, basis of genetic information, or any other group protected by law.


People with disabilities who need a reasonable accommodation to apply for or compete for employment with Conduent may request such accommodation(s) by clicking on the following link, completing the accommodation request form, and submitting the request by using the “Submit” button at the bottom of the form. For those using Google Chrome or Mozilla Firefox please download the form first: click here to access or download the form. You may also click here to access Conduent’s ADAAA Accommodation Policy.


At Conduent, we value the health and safety of our associates, their families and our community. Under our current protocols, we do not require vaccination against COVID for most of our US jobs, but may require you to provide your COVID vaccination status, where legally permissible.

 
 

Location: Company:

 
 

Description
Humana Healthy Horizons in Louisiana is seeking a Addictionologist/Addiction Services Manager (ASM) who will be responsible for overseeing the development and implementation of Humana Medicaid’s Addiction Services in Louisiana, serving the needs of children and adults with substance use disorder (SUD), including referring enrollees to social supports and community resources. They will coordinate and collaborate with the plan COO, BH Coordinator, Quality Management Coordinator, and BH Medical Director to assure quality, appropriate utilization management, and adequacy of the addiction provider network.
Responsibilities
– Assist in the development of comprehensive care programs for Louisiana’s youth and adult population affected by SUD.
– Assist in the development and management of an addiction provider network.
– Influence and assist market and corporate leadership in strategic planning to achieve better BH outcomes.
– Advise case management and other clinical associates serving members with SUD to ensure timely, culturally-competent, and appropriate delivery of addiction care and support.
– Participate as a member of Humana’s broader care team to support Case Management in accessing addiction support for the member and family.
– Provide input for conducting comprehensive member assessments to identify enrollees’ individual needs and for performing clinical intervention through the development of a care treatment plan specific to each enrollee.
– Facilitate case management consultations and provide clinical guidance for contracted providers.
– Advocate for patients and their families to ensure patients’ needs and choices are fully represented and supported by network providers in a timely and appropriate manner.
– Participate in the ongoing identification of high-risk enrollee demographic groups who may qualify for services.
– Assist in the coordination of psychiatric and community referrals to enhance enrollee supports for addiction treatment and prevention services.
– Ensure compliance with the addiction principles of care and application of American Society of Addiction Medicine (ASAM) placement criteria for all addiction program development.
Required Qualifications
– Must reside in Louisiana.
– Licensed Addiction Counselor (LAC) or 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: Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC) , Licensed Marriage and Family Therapist (LMFT) , Licensed rehabilitation counselor (LRC) , Advanced Practice Registered Nurse (APRN) with specialization in adult psychiatric and mental health, Physician (Psychiatrist) , Medical Psychologist , Licensed Psychologist
– Minimum seven (7) years of clinical experience with addiction treatment of adults or children experiencing substance use problems and disorders.
– Leadership/management experience.
– Proficiency in Microsoft Office programs specifically Excel and PowerPoint.
– Must have the ability to provide a high speed DSL or cable modem for a home office.
– A minimum standard speed for optimal performance of 25×10 (25mpbs download x 10mpbs upload) is required.
– Satellite and Wireless Internet service is NOT allowed for this role.
– A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
– 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.
Preferred Qualifications
– More than three (3) years of leadership/management experience.
– Experience working with members experiencing complex mental health and substance use disorder (SUD).
– Experience providing training, mentoring, and educational support to others.
Additional Information
– Workstyle : Hybrid Home – Works 1 – 2days/week in Humana’s Metairie, LA office location and 3 – 4 days remotely.
– Travel: As business needs require.
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

 
 

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Description

Humana Healthy Horizons in Louisiana is seeking an Associate Director, Care Management who will use clinical knowledge, communication skills, and independent critical thinking skills to provide the best and most appropriate treatment, care or services for members. He/she will lead teams of nurses and behavioral health professionals responsible for care management. The Associate Director, Care Management requires a solid understanding of how organization capabilities interrelate across department(s). They will coordinate and communicate with providers, members, or other parties to facilitate optimal care and treatment.

Responsibilities

The Associate Director leads and guides others in providing integrated services to and for our customers. Provides ongoing associate coaching and feedback to enhance associate contribution, competency, and performance.

• Oversees day to day operations and associates for Louisiana Medicaid Care Management.
  
• Achieve performance metrics for a fast paced comprehensive case management environment.
  
• Assure compliance with mandated and corporate policies regarding other departmental areas such as medical management, utilization management and case management.
  
• Develop team members and creates department process flows.
  
• Will directly lead multiple managers and highly specialized professional associates.
  
• Oversees the assessment and evaluation of members’ needs and requirements to achieve and/or maintain optimal wellness state by guiding members/families toward and facilitate interaction with resources appropriate for the care and well-being of members.
  
• Maintain compliance with Louisiana Department of Health (LDH), Department of Health and Human Services (DHHS), and the Centers for Medicare and Medicaid Services (CMS) guidelines and contractual requirements.
  
• Decisions are typically related to identifying and resolving complex technical and operational problems within department(s).
  

Required Qualifications

• Must reside in the state of Louisiana.
  
• Unrestricted Registered Nurse (RN) license in the state of Louisiana.
  
• Minimum five (5) years of previous clinical experience.
  
• Minimum of five (5) years of management/supervisory experience in the healthcare field.
  
• Proficiency in analyzing and interpreting data trends.
  
• Progressive business consulting and/or operational leadership experience.
  
• Comprehensive knowledge of Microsoft Office applications including, PowerPoint Word, Excel, and Outlook.
  
• Demonstrated knowledge of keyboard, Word, Excel, PowerPoint, email, and other Office software applications.
  
• 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.
  
• Must have the ability to provide a high speed DSL or cable modem for a home office.
  
• A minimum standard speed for optimal performance of 25×10 (25mpbs download x 10mpbs upload) is required.
  
• Satellite and Wireless Internet service is NOT allowed for this role.
  
• A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
  
• 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.
  

Preferred Qualifications

• Bachelor’s or Master’s Degree in nursing, public health, health administration, health policy or business.
  
• Knowledge of Humana’s internal policies, procedures and systems.
  
• CCM (Certified Care Manager).
  
• Experience with health promotion, coaching and wellness.
  
• Knowledge of community health and social service agencies and additional community resources.
  

Additional Information

• Workstyle : Hybrid Home – Works 1 – 2days/week in Humana’s Baton Rouge or Metairie, LA office location and 3 – 4 days remotely.
  
• Travel: Up to 25% of the time within the state of Louisiana.
  
• Direct Reports: Up to 8 Managers/Associates.
  

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 comput 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
 

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Overview

About Public Consulting Group

Public Consulting Group, Inc. (PCG) is a leading public sectorsolutions implementation and operations improvement firmthat partners with health, education, and human services agencies to improve lives. Founded in 1986 and headquartered in Boston, Massachusetts, PCG has over 2,500 professionals in more than 60 offices worldwide.PCGs Technology Consulting practice offers a full spectrum of quality Information Technology (IT) services to help state and local government agencies at every stage of the IT life cycle.Through its specialized IT services, PCGs Technology Consulting team finds cost-effective ways to help agency partners deliver successful IT systems that enhance the lives of the user base. To learn more, visit

Responsibilities

Consultant/Analyst will provide a combination of Medicaid and Project Management expertise in monitoring project lifecycle implementations in waterfall, agile and/or hybrid methodologies and providing advisory services on best practices and problem remediation strategies. The incumbent will assess project status progress and quality in accordance with PMI standards as applied in the context of eligibility systems design, development, implementation, and operations. The successful candidate will have either state agency or vendor experience with state Medicaid eligibility systems which includes knowledge of eligibility programs and state options. Experience as an eligibility worker, supervisor, or state eligibility program or operations manager highly preferred. The Consultant will report to the team leader on project status through participation and observation of DDI activities in the requirements, construction, system integration testing, UAT, and go-live phases of DDi activites. Will contribute to deliverables and work products delivered by the by the team. These deliverables and work products will be completed in accordance with our overall strategy, approach, and methodology.

Provides project management and technical expertise on large-scale IT projects

Supports development of all deliverables, status reports and other work products

Supports activities to plan and oversee all project work and develop/manage any potential organizational change management strategies or processes that might be needed

Support the goals and outcomes of the project stakeholders

Support Developing, managing, and updating Project Plan and other project documents (e.g., Communication Plan, Risk Plan, Stakeholder Register, Resource Plan)

Support and or develop, manage, and update the execution of the Project Schedule to ensure project scope and applicable milestones are met

Support or develop and deliver regular status reporting

Identifies, tracks, and manages project risks; including coordination for risk mitigation

Identifies, tracks, and manages project issues; including coordination for issue resolution

Establish a response and track the response to project recommendations (e.g., Quality Assurance (QA) vendor recommendations)

Provide ongoing communication (e.g., email, meetings) to provide project status

Collaborate with the projects Communication Manager to enhance communication efforts

Review project and related operational processes and provide input for improvement by implementing relevant lean or agile strategies

Conduct Agile Project Management and Organizational Change Management workshops

Qualifications

Required:

Direct experience with state Medicaid eligibility systems

State agency work experience with Medicaid, SNAP, TANF or other health and human service programs

Self-directed and reports to the Engagement Manager

3+ years of prior project management experience using both Agile and Waterfall techniques in IT related projects to include operations, infrastructure, and application development projects

Demonstrated ability to work directly with diverse business and technical team members in a strong team-oriented environment

Desired:

Certified Scrum Master or PMI Agile Certified Practitioner certification

QA / IV&V experience preferred

PMI Project Management Professional certification

EEO Statement

Public Consulting Group is an Equal Opportunity Employer dedicated to celebrating diversity and intentionally creating a culture of inclusion. We believe that we work best when our employees feel empowered and accepted, and that starts by honoring each of our unique life experiences. At PCG, all aspects of employmentregarding recruitment, hiring, training, promotion, compensation, benefits, transfers, layoffs, return from layoff, company-sponsored training, education, and social and recreational programsare based on merit, business needs, job requirements, and individual qualifications. We do not discriminate on the basis of race, color, religion or belief, national, social, or ethnic origin, sex, gender identity and/or expression, age, physical, mental, or sensory disability, sexual orientation, marital, civil union, or domestic partnership status, past or present military service, citizenship status, family medical history or genetic information, family or parental status, or any other status protected under federal, state, or local law. PCG will not tolerate discrimination or harassment based on any of these characteristics. PCG believes in health, equality, and prosperity for everyone so we can succeed in changing the ways the public sector, including health, education, technology and human services industries, work.

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Job Locations US-MS-Jackson US US-TX-Austin US-GA-Atlanta US-TN-Nashville

Posted Date 3 months ago (5/9/2022 7:04 PM)

Job ID 2

# of Openings 1

Category Consulting

Type Regular Full-Time

Practice Area Technology Consulting

Public Consulting Group is an equal opportunity employer. All qualified applicants receive consideration for employment without regard to race, color, religion, gender, national origin, age, sexual orientation, gender identity, protected veteran status, or status as a qualified individual with a disability. VEVRAA Federal Contractor.
 

Clipped from: https://jobs.wpri.com/jobs/senior-business-analyst-medicaid-eligibility-systems-augusta-maine/689301313-2/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Remote opportunity for a Michigan-based Network professional.

Relocation is available.

The Lead Director, leads a team of Provider Relations and Contracting resources who design, develop, manage and/or implement strategic network configurations and effective managed care network relationships.

Oversees Provider Relations team(s) that manage the service needs for providers including network/provider relations policy, recruitment, education and training, as well as improved workflows.

Oversees the development of programs to maintain and enhance collaborative provider relationships and
operational effectiveness.

Manages the activities of the network development team, including effective strategies to build progressive provider partnerships.

Maintains accountability for related compliance,
quality and financial goals.

Maintains accountability for contractual relationships with providers according to prescribed financial guidelines with all provider types including at risk, IPA/IPO, hospital and large provider/provider groups.

Ensures necessary review, oversight and support network filings in compliance with state and federal regulations.

Accountable for cost arrangements and contract performance in support of network quality, availability and financial strategies to achieve cost management goals.

Ensures network coverage adequacy and implements action items to close gaps.

Responsible for advancing the adoption of value-based payment models.

Analyzes data and is responsible for understanding medical cost issues and trends; collaborates with Medical Economics to monitor and identify scorable action plans; works closely with Population Health, Quality, and Medical Management teams to enable and improve clinical outcomes.

May work with VBC Engagement managers to develop VBC arrangements and collaborative agreements.

 
 

 
 

 
 

 
 

 
 

Clipped from: https://www.ziprecruiter.com/c/CVS-Health/Job/Lead-Director,-Network-Management-(Remote-Michigan-Based)(Medicaid)/-in-Home-Township,MI?jid=9a5f54dd4fc34079&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Description

Location: Hybrid/Mainly remote – must be able to commute to nearest Elevance Health office. East Coast States Preferred

Hours: Standard, Monday-Friday 8-5p/9-6p EST

The Marketing Communications Coordinator II is responsible for facilitating all steps of moderately complex marketing communication (Marcom) project workflows.

Primary duties may include, but are not limited to:

• Works with Marketing Communications areas to facilitate projects through all stages (research, design, writing, proofreading, review, printing, mailing and archival) to ensure the product is produced in a timely, accurate, and effective manner.
  
• Acts as primary client interface and collaborates with business partners and SMEs on projects.
  
• Reviews requests and recommends communication solutions.
  
• Schedules and leads project meetings with business partners.
  
• Acts as project manager for workflow process and is responsible for ensuring consistency and standardization on all materials.
  
• Coordinates project reviews and re-negotiates terms/deadlines as appropriate.
  
• Creates production schedules, assigns form numbers, requests source files and manages the production process of materials.
  
• Seeks out opportunities for process improvements/efficiencies, and supports business initiatives (standardization, going paperless, etc.).
  

Minimum Requirements:

• Requires a BA/BS degree and a minimum of 3 years of related experience; or any combination of education and experience, which would provide an equivalent background.
  

Preferred Skills, Capabilities and Experiences:

• Prior health care industry experience and project/process management skills preferred.
  
• Experience with Workfront is highly desirable.
  
  
  

 
 

Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Be part of an Extraordinary Team

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.

We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

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.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealthinc.com. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ability@icareerhelp.com for assistance.

 
 

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The Medical Director will be responsible for managing health plan medical costs and assuring appropriate health care delivery for plans and members. They will be responsible for leading the organizations efforts to achieve excellence in healthcare affordability, quality, member experience, and improved population and member outcomes. They will serve as a clinical leader for teams dedicated to concurrent review, prior authorization, case management and clinical coverage review.

– Share the health plan’s passion for evidence-based medicine and be comfortable applying evidence-based guidelines. Collaborate with other senior leaders in efforts that enhance the quality of care delivery, improve outcomes, and improve value delivered to our members.
– The Medical Director can expect to perform the following functions:
– Support pre-admission review, utilization management, concurrent and retrospective review process and case management.
– Provide professional leadership and direction in the utilization/cost management (UM) and clinical quality improvement (QI) of the health plan, as measured by benchmarked UM and QI goals.
– Work collaboratively as a clinical resource to other plan functions that interface with medical management such as provider relations, member services, benefits, claims management, etc.
– Ensure members receive safe, effective, equitable, efficient, timely and patient-centered health care services within their health plan benefits.
– Carry out medical policies at the health plan consistent with NCQA and other regulatory bodies.
– Participate and/or chair clinical committees and work groups as assigned.
– Review medical care, medical service, and pharmacy requests against established clinical guidelines and make approval and denial determinations in accordance with evidence-based standards, organizational policies and procedures, and regulatory requirements.
– Identify potentially unnecessary services and care delivery settings, and recommend alternatives, as appropriate.
– Review appeals of medical and pharmacy denials against established clinical guidelines and make approval and denial determinations in accordance with evidence-based standards, organizational policies and procedures, and regulatory requirements.
– Identify opportunities for corrective action plans to address issues and improve plan and network managed care performance.
– Collaborate with Provider Networks and Medical Director team in creating and maintaining programs that incentivize providers to achieve selected utilization/cost and quality outcomes.
– Participate in the retrospective review and analysis of plan performance from summary data of paid claims, encounters, authorization logs, compliant and grievance logs, and other sources.
– Provide periodic written and verbal reports and updates as required in the Quality Management Program description, the Annual QI Work Plan.
– Assure plan conformance with legal and regulatory requirements; support NCQA qualification activities, including site visits and response to accrediting and regulatory agency feedback.
– Participate in risk management, claims administration, pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, site visit review coordination, triage, nutrition service review, provider orientation, credentialing, profiling, etc.
– Conduct quality improvement and outcomes studies as directed by the state and federal regulatory agencies, the Quality Management Committee, Medical Advisory Committee, Peer Review Committee, and management.
– Support grievance process, as led by Chief Medical Officers, ensuring a fair outcome for all members.
– Monitor member and provider satisfaction survey results and implement changes as needed to increase satisfaction and assure that satisfactory relationships are maintained between network and plan participants.
– May be asked to chair various health plan committees, such as Quality Management subcommittees on Peer Review or Credentialing.
– Promote wellness and ensure programs of prevention, education and outreach to members and providers consistent with the company’s Mission, Ambition, and Values
– Perform and oversee in-service staff training and education of professional staff.
– Contribute to the development of strategic planning for existing and expanding business; recommend changes in program content in concurrence with changing markets and technologies.
– Participate in key marketing activities and presentations, as necessary, to assist the marketing effort.

 
 

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Experienced Managed Care Project Manager needed to have an integral role in Plan success. We offer a flexible office based schedule and a great salary and benefits package.

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 Health Plan Director Plan Operations and Administration. The Market Executive Projects Mgr will identify, plan, develop, and execute strategic initiatives and all activities. The Manager is responsible for recommending regulatory, process and cost efficiency solutions and collaborating with appropriate internal and external staff. This position plays a key role in in a variety of projects by performing operational assessments and analyses, researching and identifying best practices, facilitating groups and teams, managing projects, presenting results and recommendations, developing executive summaries and presentations and developing measurement tools, to improve operating processes toward greater efficiency and effectiveness and adherence to regulatory and contractual requirements. This position will work collaboratively with the leadership team to manage the flow of information and articulate the goals of the organization and state agency initiatives. Responsible for gathering from functional areas to document how we are working towards these goals and develop presentations to explain progress towards these goals. Provide detail and summary level presentations of data, including written interpretation of analytic results. Prepare PowerPoint documents for both internal and external presentations. Prepare results for senior leadership, including data driven business recommendations. Lead special projects at the direction of the Director, Plan Operations and Administration and Market President. Create and manage dashboards for the internal and external leadership as well as develop reporting tools.

The position will provide assistance and coordinate closely with the Contract Account Manager and will require excellent organization, informal and formal leadership, and mentoring skills while possessing the ability to lead others by example to achieve overall departmental/organizational goals.

This person will use knowledge of plan benefits, as well as expertise in extracting, analyzing and organizing output of data to be pro-active in developing and implementing strategies that significantly mitigate risk to the organization and client.

Education/ Experience:

• Bachelor’s Degree (e.g., Healthcare, Business, etc.) or equivalent education and experience required.
  
• Experience within healthcare operations required.
  
• Experience with healthcare related (not IT/IS) project management required.
  
• 3 years experience in a healthcare/MCO preferred.
  
• Experience in performance/process improvement.
  

 
 

Clipped from: https://www.glassdoor.com/job-listing/market-executive-projects-manager-amerihealth-caritas-JV_IC1154178_KO0,33_KE34,53.htm?jl=1007726731061&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Department

Department:DC Medicaid – Provider Service

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

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.

#LI-NH2

 
 

Clipped from: https://www.glassdoor.com/job-listing/representative-provider-relations-i-dc-medicaid-carefirst-bluecross-blueshield-JV_IC1138213_KO0,47_KE48,78.htm?jl=1008079091375&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic