Category: Curator- Job Hunter

 
 

Job Description

Reporting to the Senior Vice President, National Medicaid and the MAS VPof MSBD, the Market Medicaid line of business leader is responsible for the overall performance of the market Medicaid line of business program, with a focus on financial performance and membership growth. Oversees all aspects of market Medicaid programs, state contracting arrangements, product development, compliance with State and Federal Policies and requirements, and partnerships with market [Permanente] and Administration. Strategically builds, manages and sustains external business relationships, particularly with state and local regulators. Accountable for product development, administrative processes, interdepartmental communication, and regulatory requirements. Develops an annual strategic plan and updates market and National Executive Sponsorship on strategic issues/development, business performance, and progress against objectives. Demonstrated passion and creativity in developing models of care serving low income vulnerable populations. Essential Responsibilities: Position the market as the leader for quality, care delivery for high need vulnerable populations. The position is responsible for customer experience, achieving membership growth targets, overseeing the Medicaid product portfolio (TANF, ABD, LTSS and Adult Expansion), and developing/executing market Medicaid strategy based on state and CMS requirements, national standards and alignment with overall national and market strategy. This position incorporates care delivery requirements into strategy and develops a strong partnership with medical group and health plan delivery system operations and quality. Demonstrated strategic thinking with ability to balance long-term direction with need for immediate impact and results. Maintain awareness of the competitive landscape and market trends. Develop capacity to identify new business opportunities for the market to expand its Medicaid footprint. Recognize industry trends and Identify initiatives for market to demonstrate innovation, which could take the form of creative partnerships, marketing, member retention, care delivery or delivery system improvements, or participation in innovative projects managed by the federal government, community or provider partners. Ensure market Medicaid plans adhere to national guidance and are aligned with market business strategies, goals and initiatives and lead development of annual market Medicaid membership targets with market forecasting lead. Participate in market forums to ensure alignment of Medicaid strategies with market business plans and assure full integration of Medicaid where applicable; participate in other market forums and serve as the market voice of Medicaid. Serve as principal contact within the region for Medicaid and interface regularly with market executives (MSBD, CFO, HManage the relationship and activities with functional areas as business, regulatory, operations, legal and IT. Market Medicaid Operations Manage the relationship and activities with functional areas as business, regulatory, operations, legal and IT. Oversee and coordinate the validation and submission of state required reports and work in collaboration with NMER for timely, accurate and complete submission of encounter data. Coordinate resources so that they leverage/align with other initiatives through the organization. In conjunction with National Medicaid implement market geographic and product line Medicaid expansions. Set key performance metrics and ensure that the Medicaid line of business is well-served and drive continuous improvement initiatives related to Medicaid. Stakeholder Outreach Represent KP with state regulators, departments and representatives as well as local health departments and community-based organizations. Proactively anticipate and respond to state and federal initiatives which impact Medicaid. Manage contractual arrangements with the states, local Departments of Health, and providers including, but not limited to, transportation providers, School Based Health Centers, Federally Qualified Health Centers and CSBs. Medicaid compliance and regulatory Maintain a deep understanding of state and CMS Medicaid regulations, collaborate with National Medicaid Compliance to ensure all market functions are aware of and compliant with state and CMS Medicaid requirements. Identify market compliance risks and escalate issues as necessary to market and national Medicaid compliance and line of business leaders. Lead State Medicaid audits. Accountable for market remediation of compliance risks with market functional leaders, as needed. Financial Accountability, State Medicaid Capitation and Rate Development Accountable for the market Medicaid line of business P&L and department budget. Coordinate the market development of rate development templates for annual capitation rates. In conjunction with Actuarial services and Finance represent the market in capitation rate negotiations. Identify revenue and expense opportunities for increased state reimbursement and internal, fiscal improvement opportunities. Lead and develop market Medicaid LOB staff Ensure market line of business structure is designed to achieve desired outcomes based upon best practices. Hire, onboard, develop and coach market Medicaid staff to sustain a strong and diverse talented team and advance Medicaid performance. Provide opportunities for market staff to learn about the national Medicaid line of business and functional areas to contribute to building their expertise and expand their view of the business line. Ensure leadership succession plans are in place so that key positions can be backfilled with appropriate talent. Basic Qualifications: Experience Minimum ten (10) years of relevant experience in a Medicaid managed care organization. Minimum seven (7) years of management experience. Minimum five (5) years in product line management to special populations. Education Bachelors degree or four (4) years relevant experience. High School Diploma or General Education Development (GED) required. License, Certification, Registration N/A Additional Requirements: Strong background working with Medicaid and/or Special Populations and unique health care needs. Understanding of state and federal Medicaid framework and regulatory requirements Excellent negotiation skills, verbal/written communication skills. Strong analytical and strategic planning skills. Excellent public presentation skills. Strong persuasive and interpersonal skills. Knowledgeable of Medicaid health care delivery systems Knowledgeable of current trends in care management an industry related to care delivery to Medicaid population. Demonstrated ability to build effective partnerships and influence others who may have different perspectives. Must be a decisive, results-oriented manager or people. Must excel in developing a highly focused, cohesive team of professionals who are comfortable working in a team environment. Demonstrated ability to work in a highly matrixed environment. Strong collaborative and team skills. Preferred Qualifications: Twelve (12) years of relevant experience in a Medicaid managed care organization preferred.

 
 

Clipped from: https://b-jobz.com/us/web/jobposting/3022427019?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Position:  Director, Behavioral Health Network & Market Strategy (Medicaid)
** Description*
* The Director, Behavioral Health (BH) Network and Market Strategy will insure that the appropriate providers are engaged and recommend clinical models based on specific behavioral health market needs. Conducting new market evaluation, RFP development and implementation. This position will work cross functionally with business development teams and provider contracting.

** Responsibilities*
* + Leads strategy for advance market intelligence to improve RFP responses and implementation efforts

+ Assesses Medicaid BH provider network needs for each market (services, provider/facility types, network adequacy), supports geographical analysis of member access to care gaps.

+ Support BH provider recruitment for new business and expansions

+ Support provider contract review and onboarding

+ Assesses local value-based care opportunities, supports value based provider recruitment/ contracting

+ Supports the development of VBC models – payment model design (full or partial risk, PPPM, upside only, shared savings, performance/outcomes-based contracting etc.). Supports the conceptual framework for measuring VBP program outcomes.

+ Identifies provider integration contracting opportunities (FQHCs, PCP/BH, BH Integrated Health Homes, rural health clinics)

+ Researches new market BH systems of care and identifies gaps in care/services

+ Development of network and provider relations training strategy

+ Works closely with operational and Clinical leaders within Medicaid and across the organization

+ Researches and recommends clinical models that address the needs of various sub-populations of membership (youth suicide, Trauma, chronically mentally ill and SUD adolescents/adults, etc.)

** Required

Qualifications:

*
* + Bachelor’s degree

+ 3 years Network and provider relations experience

+ 8 s of progressive work experience in the health insurance industry

+ 5 s of management experience in a Medicaid managed care environment

+ 3 s of behavioral health experience

+

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

+ We will require full COVID vaccination for this job as 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 documentation for a medical or religious exemption consideration where allowed by law. Requests for these exemptions should be submitted at least 2 week prior to your scheduled first day of work.

** Preferred

Qualifications:

*
* + Master’s Degree

** Additional Information*
* This position will report to the VP, Medicaid Behavioral Health, and will have approximately 4-6 Direct reports

** Scheduled Weekly Hours*
* 40

 
 

Clipped from: https://www.learn4good.com/jobs/washington/district-of-columbia/healthcare/1123100062/e/

 
 

Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that’s improving the lives of millions. Here, innovation isn’t about another gadget, it’s about making health care data available wherever and whenever people need it, safely and reliably. There’s no room for error. Join us and start doing your life’s best work.(sm)

Positions in this function have primary responsibility for requirements documentation for all aspects of Encounter Management.

Positions in this function conduct analyses, assist in the solutioning, and development of data maps both to load BHEMIS SQL database objects and for mapping processes from BHEMIS to HIPAA Compliant Implementation Guide (IG) and Customer Companion Guide (CG) Transaction documentation and/or other proprietary formats to meet Customer/client requirements as well as all associated documentation.

Generally work is self-directed for both prescribed and non-prescribed processes.
Works with less structured, new, highly complex issues.
Serves as BHEMIS Data Mapping Subject Matter Expert (SME).
Comfortable working in a dynamic, rapidly changing work environment.

Primary Responsibilities:

• Demonstrate and apply knowledge of medical and/or behavioral health claims and general encounter processing and management best practices
  
• Demonstrate and apply intimate knowledge of HIPAA transaction guides, data elements and use requirements
  
• Demonstrate and apply knowledge of federally mandated Companion Guide guidelines and their use
  
• Demonstrate and apply basic relational database concepts and familiarity
  
• Conducts/updates/manages analyses and document transaction requirements based on IG/CG and proprietary format instructions
  
• Identifies data gaps and manages remediation of same
  
• Assists in the development/creation/documentation of data maps from SQL to HIPAA/proprietary transactions using ETL software
  
• Conduct mapping/code audits of all maps prior to release
  
• Creating, managing and running scheduled mapping/transaction generation jobs
  
• Conducts research as needed using a variety of tools (SQL Management Studio, XMLSpy, UltraEdit, etc.).
  
• Assists data and report analysts in developing data validation routines
  
• Acts as primary liaison between BHEMIS and Customer/client production personnel
  
• Demonstrate and apply a strong attention to detail
  
• Creates various work products using standard software packages (Word, Excel, Visio)
  
  
  

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:

• Bachelor’s degree
  
• 4+ years of experience with medical or behavioral health claims processing
  
• 2+ years of experience of MS Excel, Word, Visio
  
• 1+ years of experience with T-SQL
  

Preferred Qualifications:

• Experience working as a Business Analyst.
  
• NEMIS
  
  
  

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment

Careers with Optum. Here’s the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world’s large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life’s best work.(sm)

Colorado, Connecticut or Nevada Residents Only: The salary range for Colorado residents is $82,100 to $146,900. The salary range for Connecticut / Nevada residents is $90,500 to $161,600. 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.

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


 

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

 
 

Clipped from: https://www.glassdoor.com/job-listing/edi-bus-consultant-analyst-medicare-medicaid-encounters-telecommute-optum-JV_IC1130324_KO0,67_KE68,73.htm?jl=1007792598715&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Overview:

Company Overview:

CoventBridge Group is the leading worldwide full-service investigation solutions company providing: Surveillance, SIU and Compliance, Claims Investigation, Counter-Fraud Programs, Desktop Investigations, Social Media, Record Retrieval, Canvasses and Vendor Management programs. With offices in the UK and U.S. the company provides top tier data privacy and security practices, deploys robust case management technology customized to clients’ needs and delivers worldwide coverage via its 1000 employees and affiliates worldwide.

About the Opportunity:

 
 

The Medicaid Fraud SME will be responsible for activities related to fraud investigation development

In assuming this position, you will be a critical contributor to meeting CoventBridge Group’s objective: To provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste and abuse.

This position will report directly to the Program Integrity Supervisor and will work in our Grove City, OH office or if not local, remotely from a home office.

Responsibilities/ Requirements:

Responsibilities:

• Identify proactive data analysis study ideas, working closely with the Data Analysis, Medical Review and Program Integrity teams to ensure actionable leads with ROI that meets CMS requirement
  
• Develop and coordinate investigative approaches and plans for fraud leads in order to expedite the investigative progress
  
• Help establish and maintain relationships with State Medicaid Agencies and CMS
  
• Produce and submit required reports according to pre-established time guidelines
  
• Support team in meeting quality and production standards
  
• Monitor security of evidence gathered during the development of fraud investigations
  
• Ensure departmental compliance with Quality Management System and ISO requirements
  
• Perform other duties as assigned by the Manager that contribute to task order goals and objectives
  

Requirements:

• Minimum of two (2) years of experience in Medicare or Medicaid fraud investigations including investigation development, data analysis, and problem identification or one (1) year of experience with an advanced degree
  
  
  
• Excellent oral, written and verbal skills.
  
• Ability to work independently and with minimal supervision.
  
• Knowledge of statistics, data analysis techniques, and PC skills are preferred.
  
• Must have and maintain a valid driver’s license issued by the state of residence.
  

Educational Qualifications:

• Bachelor’s Degree or equivalent related experience
  
• Preference will also be given to those individuals that have attained the Certified Fraud Examiners (CFE) designation or Accredited Health Care Fraud Investigator (AHFI)
  

 
 

Benefits:

Benefits:

• Medical, Dental, Vision plans
  
• Life, LTD and STD paid by the employer
  
• 401(k) with company match up to 4%
  
• Paid Time Off and company paid holidays
  
• Tuition assistance after 1 year of service
  

*CoventBridge is proud to be an EEO-AA employer M/F/D/V.*

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

UPIC

 
 

Clipped from: https://www.glassdoor.com/job-listing/medicaid-fraud-sme-subject-matter-expert-coventbridge-group-JV_KO0,40_KE41,59.htm?jl=1007791983722&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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.

 
 

About Us:

We are revolutionizing the world of healthcare through digital transformation and building a world-class software engineering practice. Our high caliber team delivers leading edge technology and drives innovation to solve complex business challenges. Using collective innovation we are turning visions into action and challenging what is possible to support the healthcare of 1 in 15 individuals. 

 
 

About You:

You are a highly collaborative, strategic risk-taker driven to make a difference and change the face of healthcare. You thrive in a supportive, result-oriented community and are committed to the relentless pursuit of continuous growth. You are highly agile, excel in fast-paced environments and willing to push outside your comfort zone. You are ready to find your purpose at work

 
 

The Role:

We are transforming technology and creating a digital evolution that will empower Centene to better serve our members. Data Analyst will manipulate large data sets to provide insights and trends for our health plans. 

 
 

As Data Analyst II: 

 
 

•    Build queries to locate relevant data 

•    Analyze health management programs including: data collection, validation and outcome measurement. 

o    May include: 

?    Financial, pharmacy, claims, provider, and member data

?    IRS, CMS, HHSC, HEDIS reporting

?    Internal data cleansing and data reconciliation analysis

?    Trend analysis in various functional areas of health care management.

•    Create and generate reports through MS-Excel, MS-Access, and SQL using Business Objects interface and direct links to core databases (ODS/EDW)

•    Produce reports for and interface with senior management and internal and external stakeholders.

•    Gather and interpret business requirements and monitor data trends to proactively identify issues

•    Execute data changes and update core systems as needed

•    Handle multiple projects and timelines effectively and communicate risks and issues to manager regularly

•    Assist with training lower level Data Analysts.

 
 

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

 
 

Additionally you will bring:

 
 

•    Bachelor’s degree’s related field or equivalent experience. 

•    2+ years of statistical analysis or data analysis experience. 

•    SQL Queries

•    Requirements gathering

•    Data mining/validation

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.monster.com/job-openings/data-analyst-ii-medicaid-remote-available-st-louis-mo–32474866-5283-4d40-9359-6c259a7826ea?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

 
 

Resp & Qualifications

COMPANY SUMMARY:

CareFirst, Inc., and its affiliated companies, generally referred to as CareFirst BlueCross BlueShield (CareFirst), is the Mid-Atlantic region’s largest private sector health insurer, serving the healthcare needs of 3.5 million members in Maryland, the District of Columbia, and portions of northern Virginia. The Company offers a comprehensive portfolio of products and services to individuals and groups, as well as state and federal government sponsored plans. With a market share almost three times that of the closest competitor, the company commands 45 percent penetration across the region.

In July 2018, Brian D. Pieninck assumed the role of President and CEO after serving as the company’s COO of Strategic Business Units and IT Division. Under his leadership, the organization completed an extensive review of its operations and clinical programs, resulting in an expansive 3-year strategy to grow and diversify the company’s core business. Along with a 5-year vision to drive the transformation of the healthcare experience across the continuum of its members, partners, and communities, the company has placed a renewed and intentional focus on fostering a mission-based culture, which drives every decision the company makes. The organization employs over 5,600 full-time employees in Maryland, Northern Virginia, the District of Columbia, and West Virginia. CareFirst has earned multiple workplace awards recognizing its leadership in diversity and inclusion, wellness engagement, and creation of a supportive and equitable work environment for all employees.

At CareFirst, you are part of an inspired, collaborative team that is building the healthcare experience we want for our families and our future. Every day, we make a meaningful difference in the communities where we live and work.

We practice empathy, seek to understand, invest in inclusion, demand equity and nurture belonging every day for our employees and the communities we serve. We rely on the rich diversity of our employees’ experiences and backgrounds to achieve our mission. Every year we host a Week of Equity and Action where we deepen our investment and commitment to diversity, equity, and inclusion. During this week thousands of employees engage in workshops and volunteerism with the goal of bettering themselves and our community.

• Women make up around 70% of CareFirst’s employee population, and over 50% identify as BIPOC (Black, Indigenous, and people of color).
  
• We have 9 resource groups that connect employees over shared identities (LGBTQ, veteran status, race, etc.) and passions (climate change, healthy living, leadership development).
  
• Employees are encouraged to give back and volunteer in their communities with their civic engagement hours.
  

As a not-for-profit, CareFirst regularly ranks among the most philanthropic organizations with $65 million invested in the community in 2020 to improve overall health, and increase the accessibility, affordability, safety, and quality of healthcare throughout its market area. The company’s employees consistently add to this impact by devoting thousands of volunteer hours to numerous community organizations and social causes. The company’s continued efforts to reinvest in community health care programs has repeatedly earned CareFirst regional accolades as a leading corporate philanthropist, including the No. 2 and No. 7 spots on the Baltimore Business Journal and Washington Business Journal’s 2019 list of top corporate givers, respectively.

PURPOSE:
The Technician, Enrollment I is responsible for ensuring that members are accurately enrolled into CareFirst member enrollment systems in a timely manner, and according to the account contract or service agreement. To accomplish this, the associate in this role may interact and coordinate activity with key client account contacts, subscribers, CareFirst Sales, Underwriting, Finance, and Information Technology associates, as well as associates aligned to the Account Installation department of other BlueCross BlueShield Plans.


ESSENTIAL FUNCTIONS:

• Enroll subscribers and dependents for all lines of business as requested via fax, U.S. mail, and/or e-mail. Verify enrollment status, make changes to membership records, research and resolve enrollment system discrepancies, process membership terminations, and other forms of enrollment events. Complete monthly reconciliation process and resolve discrepancies.
  
• Coordinate with the Account Installation team as it pertains to member identification card process to ensure cards are not released until all enrollment updates are completed and audited. Coordinate with the Billing Technician to ensure that all group enrollments are processed prior to running the monthly bill.
  

QUALIFICATIONS:


Education Level: High School Diploma or GED.


Experience: less than one year experience in membership enrollment, member services, billing, claims operations, and/or data analysis.


Knowledge, Skills and Abilities (KSAs)

• Must be able to work effectively in a team environment.
  
• Must be able to adapt swiftly to multiple and rapidly changing priorities.
  
• Must be able to learn and comprehend details of client accounts, process flow diagrams, and health insurance enrollment software.
  
• Must be able to work effectively with large amounts of member enrollment data, paying close attention to detail upon entering data into the appropriate CareFirst system.
  
• Must be able to use Microsoft Office, specifically Excel.
  
• 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-Enrollment

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-LJ1

 
 

Clipped from: https://www.glassdoor.com/job-listing/enrollment-technician-i-md-medicaid-carefirst-bluecross-blueshield-JV_IC1153614_KO0,35_KE36,66.htm?jl=1007792155929&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Position:  Director, Behavioral Health Network & Market Strategy (Medicaid)
** Description*
* The Director, Behavioral Health (BH) Network and Market Strategy will insure that the appropriate providers are engaged and recommend clinical models based on specific behavioral health market needs. Conducting new market evaluation, RFP development and implementation. This position will work cross functionally with business development teams and provider contracting.

** Responsibilities*
* + Leads strategy for advance market intelligence to improve RFP responses and implementation efforts

+ Assesses Medicaid BH provider network needs for each market (services, provider/facility types, network adequacy), supports geographical analysis of member access to care gaps.

+ Support BH provider recruitment for new business and expansions

+ Support provider contract review and onboarding

+ Assesses local value-based care opportunities, supports value based provider recruitment/ contracting

+ Supports the development of VBC models – payment model design (full or partial risk, PPPM, upside only, shared savings, performance/outcomes-based contracting etc.). Supports the conceptual framework for measuring VBP program outcomes.

+ Identifies provider integration contracting opportunities (FQHCs, PCP/BH, BH Integrated Health Homes, rural health clinics)

+ Researches new market BH systems of care and identifies gaps in care/services

+ Development of network and provider relations training strategy

+ Works closely with operational and Clinical leaders within Medicaid and across the organization

+ Researches and recommends clinical models that address the needs of various sub-populations of membership (youth suicide, Trauma, chronically mentally ill and SUD adolescents/adults, etc.)

** Required

Qualifications:

*
* + Bachelor’s degree

+ 3 years Network and provider relations experience

+ 8 s of progressive work experience in the health insurance industry

+ 5 s of management experience in a Medicaid managed care environment

+ 3 s of behavioral health experience

+

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

+ We will require full COVID vaccination for this job as 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 documentation for a medical or religious exemption consideration where allowed by law. Requests for these exemptions should be submitted at least 2 week prior to your scheduled first day of work.

** Preferred

Qualifications:

*
* + Master’s Degree

** Additional Information*
* This position will report to the VP, Medicaid Behavioral Health, and will have approximately 4-6 Direct reports

** Scheduled Weekly Hours*
* 40

 
 

Clipped from: https://www.learn4good.com/jobs/aberdeen/south-dakota/healthcare/1123110341/e/

 
 

The State Personnel System is an E-Verify employer. For more information click on our E-Verify Website.

Requisition No: 618121 

Agency: Office of the Attorney General

Working Title: MEDICAID FRAUD ANALYST II – 41001041

Position Number: 41001041 

Salary:  $32,697 – $37,000 

Posting Closing Date: 04/29/2022 

This is a Full-Time Position

 
 

Our Organization and Mission: The Office represents the State of Florida in state and federal civil and criminal courts, from trial courts to the Supreme Court of the United States. 

 
 

Pay: $32,697 – $37,000 Annually 

 
 

Position Summary: This position is in the Medicaid Fraud Unit.

 
 

Qualifications: A bachelor’s degree from an accredited college or university and one year of professional experience in research, investigations, investigative analysis, or statistics.
Professional or nonprofessional experience as described above can substitute on a year-for-year basis for the required college education.

 
 

Preference will be given to candidates who have experience compiling and analyzing investigative information; and experience in the use of spreadsheets and relational database applications.

 
 

The Work You Will Do: An employee in this position provides analytical support for attorneys and investigators in Florida-specific and multistate health care fraud investigations and litigation matters. An employee in this position also performs work conducting detailed research and analysis of investigative information relating to alleged violations of applicable laws pertaining to health care fraud, in the administration of the Medicaid program, and/or the alleged abuse or neglect of patients in health care facilities governed by the State Medicaid program. An employee in this position may also perform as lead analyst on specialized complex civil enforcement investigations and litigation matters and analytical projects.

• 35 % Create customized downloads from on-line Medicaid claims data warehouse as requested by investigators, attorneys, and multistate investigative and litigation teams.
  
• 25 % Prepare reports/schedules/charts pertaining to all aspects of the analysis and research for use in criminal prosecution, civil actions and administrative referrals.
  
• 20 %  Assists and supports Medicaid fraud investigators and attorneys in the compilation and analysis of investigative information and the development of damages models for use in Florida-specific and multistate health care fraud investigations and litigation. Obtains and analyzes large amounts of data to: interpret and summarize health care fraud activity, calculate damages sustained to the Florida Medicaid program, determine significance, completeness and usefulness of data, recognize and identify patterns and trends, and brief investigators and attorneys.
  
• 10 % Extract information from investigative databases. Compile, analyze and disseminate intelligence information retrieved from various computer databases/systems. Perform various duties related to computers.
  
• 5 % Assist in the prosecution of Medicaid fraud and/or patient abuse to include testimony in courts of law pertaining to the investigation.
  
• 5 % Other duties as assigned.
  

 
 

**SKILLS VERIFICATION TEST ** All applicants who meet the screening criteria/minimum job requirements will be required to take a timed Skills Verification Test.  Applicants must receive a score of at least 70% to move to the interview phase.

 
 

Where You Will Work:
This position is in Tallahassee, Florida. Tallahassee offers everything from a vibrant arts and culture scene to great sports rivalries. It is a true college town that includes Florida State University, Florida A&M, and several smaller schools. As Florida’s capital city and a college town, you can expect a feeling of connectedness and the economic benefits that come with being in the center of state government. In addition, the capital city also offers an abundance of outdoor recreation for all ages, a diverse foodie scene and a ton of family-friendly festivals and activities year-round. Tallahassee is a small to mid-size city known for its parks and rolling red hills.  Nestled in north Florida’s panhandle, it is known as a sportsman’s paradise. It is located just 22 miles from the beautiful Gulf of Mexico, which is home to some of the world’s top beaches. In addition, the State of Florida has no state income tax for its residents.

 
 

The Benefits of Working for the State of Florida: Working for the State of Florida is more than a paycheck. The State’s total compensation package for employees features a highly competitive set of employee benefits including:

• Annual and Sick Leave benefits.
  
• Nine paid holidays and one Personal Holiday each year.
  
• State Group Insurance coverage options, including health, life, dental, vision, and other supplemental insurance option.
  
• Retirement plan options, including employer contributions (For more information, please click www.myfrs.com).
  

 
 

• Flexible Spending Accounts
  
• Tuition waivers.
  
• And more!
  

For a more complete list of benefits, visit www.mybenefits.myflorida.com.

 
 

IMPORTANT NOTICE: To be considered for the position, all applicants must:

• Submit a complete and accurate application profile necessary for qualifying such as dates of service, reason for leaving, etc.   In addition, all applicants must ensure all employment and/or detailed information about work experience is listed on the application (including military service, self-employment, job-related volunteer work, internships, etc.) and that gaps in employment are explained.  NOTE:  Any required experience and/or preferences listed in the advertisement must be verified at the time of application.
  
• Ensure that applicant responses to qualifying questions are verifiable by skills and/or experience stated on the employment application and/or resume.  Applicants who do not respond to the qualifying questions will not be considered for this position.
  
• The elements of the selection process may include a skill assessment exercise. 
  
• Current and future vacancies may be filled from this advertisement for a period of up to six months. Following the six-month period, a new application must be submitted to an open advertisement to be considered for that vacancy.
  
• OAG employees are paid biweekly.  All state employees are required to participate in the direct deposit program pursuant to s. 110.113, Fs.
  

 
 

CRIMINAL BACKGROUND CHECKS/ DRUG FREE WORKPLACE: All OAG positions are “sensitive or special trust” and require favorable results on a background investigation including fingerprinting, pursuant to s. 110.1127(2)(a), F.S.  The State of Florida supports a Drug-Free Workplace, all employees are subject to reasonable suspicion or other drug testing in accordance with section 112.0455, F.S., Drug-Free Workplace Act.  We hire only U.S. citizens and those lawfully authorized to work in the U.S.

 
 

E-VERIFY STATEMENT: The Office of the Attorney General participates in the U.S. government’s employment eligibility verification program (e-verify). E-verify is a program that electronically confirms an employee’s eligibility to work in the United States after completion of the employment eligibility verification form (i-9).

 
 

REMINDERS: Male applicants born on or after October 1, 1962, will not be eligible for hire or promotion unless they are registered with the Selective Service System (SSS) before their 26th birthday, or have a Letter of Registration Exemption from SSS.  For more information, please visit the SSS website at: https: //www.sss.gov.  If you are a retiree of the Florida Retirement System (FRS), please check with the FRS on how your current benefits will be affected if you are re-employed with the State of Florida.  Your current retirement benefits may be canceled, suspended, or deemed ineligible depending upon the date of your retirement.

The State of Florida is an Equal Opportunity Employer/Affirmative Action Employer, and does not tolerate discrimination or violence in the workplace.

Candidates requiring a reasonable accommodation, as defined by the Americans with Disabilities Act, must notify the agency hiring authority and/or People First Service Center (1-866-663-4735). Notification to the hiring authority must be made in advance to allow sufficient time to provide the accommodation.

The State of Florida supports a Drug-Free workplace. All employees are subject to reasonable suspicion drug testing in accordance with Section 112.0455, F.S., Drug-Free Workplace Act.

VETERANS’ PREFERENCE.  Pursuant to Chapter 295, Florida Statutes, candidates eligible for Veterans’ Preference will receive preference in employment for Career Service vacancies and are encouraged to apply.  Certain service members may be eligible to receive waivers for postsecondary educational requirements.  Candidates claiming Veterans’ Preference must attach supporting documentation with each submission that includes character of service (for example, DD Form 214 Member Copy #4) along with any other documentation as required by Rule 55A-7, Florida Administrative Code.  Veterans’ Preference documentation requirements are available by clicking here.  All documentation is due by the close of the vacancy announcement. 

 
 

 
 

Clipped from: https://jobs.myflorida.com/job/TALLAHASSEE-MEDICAID-FRAUD-ANALYST-II-41001041-FL-32301/873568800/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

R-276896


Description


The Financial Planning & Analysis Lead is acritical leadership role with full market financial oversight over the South Carolina Medicaid market. This is an exciting opportunity to build relationships with close to 6,000 members, with significant projected growth over the next year. The position analyzes and forecasts financial, economic, and other data to provide accurate and timely information for strategic and operational decisions. The Financial Planning & Analysis Lead works on problems of diverse scope and complexity ranging from moderate to substantial.


(While this position supports the South Carolina Medicaid market, but the candidate is not required to live in South Carolina.)


Responsibilities


The Lead, Financial Planning & Analysis collects, compiles, verifies, and analyzes financial information and economic indicators so that senior management has accurate and timely information for making strategic and operational decisions. Evaluates industry, economic, financial, and market trends to forecast the organization’s short, medium, and long-term financial and competitive position. May involve financial modeling, reporting and budgeting as well. Provides input into functions strategy.

• Provide market specific financial leadership in the state Medicaid Market, developing a deep understanding of Humana’s Medicaid strategy, capabilities, business drivers, data analytics infrastructure, operational processes, metrics and best practices
  
• Provide overall Market P&L management and leadership with budgets, forecasts, financial analysis, trends, projections and analytics.
  
• Provide Market leader support reporting out on financial results, long term planning and drive the understanding of financial performance and key drivers
  
• Responsible for financial analysis, identification of month end financial drivers, and forecasting including headcount planning to ensure compliance with state requirements
  
• Perform financial impact analysis for new contracts and support negotiations
  
• Develop Market specific strategic plans and objectives, manage against a five year long term plan and coordinate annual budget targets that meet the short and long term plan objectives
  
• Responsible for identifying medical cost trends and leadership of medical cost improvement initiatives
  
• Responsible for the business unit’s contribution to corporate
  
• Provide leadership regarding rate and pricing development
  
• Provide leadership and support regarding value based program development and administration
  
• Ensure compliance with all state regulatory financial reporting and overall state contract management
  
• Develop and manage meaningful relationships with the state Department of Health partners. Apply keen insight regarding the current Medicaid health care regulatory environment and competitive environment, and how the components of Humana’s business model interrelate to make Humana competitive in the marketplace
  
• Cultivate internal and external business relationships which will serve as resources of technical knowledge and performance improvement
  
• Lead and develop staff through all phases from recruitment to training and advancement opportunities
  
  
  

Required Qualifications

• Bachelor’s degree in finance, accounting
  
• 8 or more years of finance and/or accounting experience
  
• Knowledge of complex accounting and financial transactions for internal and external reporting
  
• Ability to lead and manage special projects that may necessitate cross-functional partnerships
  
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
  
  
  

Preferred Qualifications

• Master’s Degree in Business Administration or a CPA strongly preferred
  
• Experience advising senior leadership on financial strategies
  
• Prior Medicaid healthcare industry experience working in Finance/Accounting
  
  
  

Additional Information

• This position supports the South Carolina Medicaid market, but the candidate is not required to live in South Carolina and can work fully remote from anywhere in the U.S.
  
  
  

Vaccine Policy


For this job, associates are required to be fully COVID vaccinated, including booster 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, including booster or commit to testing protocols OR   Provide proof of applicable exemption including any required supporting documentation. Medical, religious, state and remote-only work exemptions are available.


Work-At-Home Requirements

• WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
  
• 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
  
  
  

Why Humana?

Just To Name a Few


At Humana, we know your well-being is important to you, and it’s important to us too. That’s why we’re committed to making resources available to you that will enable you to become happier, healthier, and more productive in all areas of your life.

• Work-Life Balance
  
• Generous PTO package
  
• Health benefits effective day 1
  
• Annual Incentive Plan
  
• 401K – Immediate company match
  
• Well-being program
  
• Paid Volunteer Time Off
  
• Student Loan Refinancing
  
  
  

If you share our passion for helping people, we likely have the right place for you at Humana.


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 Humana@myworkday.com with instructions to add the information into the application at Humana’s secure website.


Interview Format


As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Modern Hire to enhance our hiring and decision-making ability. Modern Hire allows us to quickly connect and gain valuable information for you pertaining to your relevant skills and experience at a time that is best for your schedule.


If you are selected for a first round interview, you will receive an email correspondence inviting you to participate in a Modern Hire interview. In this interview, you will receive a set of interview questions over your phone and you will provide recorded or text message responses to each question. You should anticipate this interview to take about 15 minutes. Your recorded interview 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.linkedin.com/jobs/view/fp-a-lead-medicaid-market-at-humana-3023957935/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

•  

GA United States

Description
SHIFT: Day Job
SCHEDULE: Full-time Be part of an extraordinary team
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?
Build the Possibilities. Make an extraordinary impact.
Anthem’s Medicaid Proposal Development Team is looking for a Director of Writing for Proposal Development to join its team. This people leader will lead our internal writing team and editors. S/he also staffs and manages our live proposal work with external writers to supplement our internal writing staff. S/he is also responsible for the completion and quality of our Medicaid Proposal writing, tracking performance, and maintaining our core content library.
(This position can work remotely from any US Anthem office)
How you will make an impact:
Responsible for directing and conducting activities related to the development of the Medicaid proposal process, to include strategic messaging and writing and/or support of effective and efficient development of responses to Requests for Proposal(s) to expand the Medicaid business in both new and existing markets. Primary duties may include, but are not limited to: Incorporates evaluation of the market and customer values and develops win themes and tactics to ensure messages are evident in the response and the Company is well-positioned to win the business. Considers the competitive environment, customer goals, objectives, and the RFP requirements in the development of strategies to deliver the Company’s messages effectively and timely. Leads and manages the writing team which includes both internal and external resources and/or leads the development of proposal tools and processes to ensure they are consistent with win themes, style guide, and other presentational tactics, as identified in the RFP Response and Leadership Strategy processes (to include issues management, document production and assessment of the proposal to drive a complete, fully compliant and effective proposal response). Hires, trains, coaches, counsels, and evaluates the performance of direct reports.

Qualifications
BA/BS degree and a minimum of 7 years of related experience including at least 5 years of leadership experience; or any combination of education and experience, which would provide an equivalent background.
Highly preferred skills and experience:
-Former proposal writing experience, preferably on Medicaid Health plan proposals
-People management experience
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 Anthem. 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 Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws.
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. Anthem is an Equal Employment Opportunity 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. Applicants who require accommodation to participate in the job application process may contact ability@icareerhelp.com for assistance.

 
 

 
 

Clipped from: https://us-jobs-today.com/job-detail/926337412/director-writingand-proposal-development-medicaid?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic