Category: Curator- Job Hunter

 
 

Description

The Medicaid Encounters Lead is responsible for monitoring and oversight of the end-to-end encounter management workflow for Humana Healthy Horizons in Florida. In collaboration with Encounters, Finance and Operations teams, the Medicaid Encounters Lead analyzes and reconciles complex encounter inbound/outbound process issues, using data from internal and external sources to identify process improvements and provide insight to decision-makers. In addition, the Medicaid Encounters Lead role ensures internal claims processing logic aligns to state encounter processing guidelines to minimize encounter rejections. This role will also be responsible for guiding and overseeing encounters reconciliation between providers and Humana. The ability to clearly articulate issues and solutions to team members, management, and external entities is crucial to the success of this Medicaid Encounters Lead role.

Responsibilities

Role Responsibilities

• Responsible for documenting, monitoring and analyzing the end-to-end encounter life cycle, both inbound and outbound.
  
• Identify and interpret encounter data, submission requirements and performance metrics per regulatory and health plan guidelines.
  
• Research and document all encounter errors in systems/databases; perform encounter data reconciliation and statistical and trend analysis.
  
• Oversee the reconciliation processes for delegated vendors and risk providers to ensure the Plan has received all submitted encounters.
  
• Perform root cause analysis of claims/encounters processing and submission issues; communicate with management and provide recommendations.
  
• Collaborate with other departments on designing and implementing system/business process adjustments as needed to meet encounter data processing and submission goals.
  
• Communicate with and provide clear documentation to other departments on issues causing encounter pends/denials and potential solutions.
  
• Develop encounter-related reports (e.g. exception reports, root cause analysis outcome reports, etc.) and provide to other departments for error resolution, follow-up and performance monitoring.
  
• Participate in resolving encounter data and process issues.
  
• Review and research inquiries from regulatory bodies and/or health plans related to submission data, including score cards from health plans.
  

Required Qualifications

• Bachelor’s degree in a healthcare field or equivalent experience.
  
• 5+ years of experience in managed healthcare analysis, preferably as a Business Analyst or similar role.
  
• 2+ years of project leadership experience.
  
• Advanced experience working with big and complex data sets within large organizations.
  
• Advanced in SQL, SAS, and other data systems.
  
• Comprehensive knowledge of all Microsoft Office applications, including Word, PowerPoint, Outlook, and Excel.
  
• Experience with user acceptance testing, training, writing business requirements, and mapping business processes.
  
• Demonstrated experience with problem solving and process improvements; ability to give direction and make sound business decisions.
  
• Must have a room in your home designated as a home office; away from high traffic areas where confidential information may be secured.
  
• Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10×1 (10mbs download x 1mbs upload) is required.
  
• For this job, associates are required to be fully COVID vaccinated or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are a healthcare company committed to putting health and safety first for our members, patients, associates, and the communities we serve.
  
• If progressed to offer, you will be required to: Provide proof of full vaccination OR Commit to weekly testing, following all CDC protocols, OR Provide documentation for a medical or religious exemption consideration. This policy will not supersede state or local laws. Requests for these exemptions should be submitted at least 2 weeks prior to your scheduled first day of work.
  

Preferred Qualifications

• Experience with Florida Medicaid encounters.
  
• Experience with ANSI X12 EDI standards for healthcare.
  

Additional Information

• Workstyle: Remote or Hybrid Office. The workstyle will be Hybrid Office if you live in a commutable distance to the Humana Healthy Horizons office location in Tampa, FL. Hybrid office is defined as working 3 – 4days/week in the office location and 1 – 2 days/week remote. Leadership will determine the frequency.
  
• Work Hours: Eastern Standard Time.
  
• Direct Reports: up to 2 associates
  
• Travel: up to 10%
  

Scheduled Weekly Hours

40

 
 

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Description:

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? 

Medical Director – Washington Medicaid 

Responsible for the administration of physical and/or behavioral health medical services, to ensure the appropriate and most cost effective medical care is received. May be responsible for developing and implementing programs to improve quality, cost, and outcomes. May provide clinical consultation and serve as clinical/strategic advisor to enhance clinical operations. May identify cost of care opportunities. May serve as a resource to staff including Medical Director Associates. May be responsible for an entire clinical program.

How you will make an impact:  

• Supports clinicians to ensure timely and consistent responses to members and providers.
  
• Provides guidance for clinical operational aspects of a program.
  
• Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations, and patients’ office visits with providers and external physicians.
  
• May conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations.
  
• Serves as a resource and consultant to other areas of the company.
  
• May be required to represent the company to external entities and/or serve on internal and/or external committees. May chair company committees. Interprets medical policies and clinical guidelines.
  
• May develop and propose new medical policies based on changes in healthcare.
  
• Leads, develops, directs and implements clinical and non-clinical activities that impact health care quality cost and outcomes.
  
• Identifies and develops opportunities for innovation to increase effectiveness and quality. 
  

Qualifications

• Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA).
  
• Must possess an active unrestricted medical license to practice medicine or a health profession. 
  

 
 

• Currently licensed in the state of Washington or willing to obtain WA license. 
  
• Minimum of 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
  
• Ability to work Monday thru Friday, 8am-5pm PST
  

Preferred Qualifications

• Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
  
• Family Medicine or Pediatrics preferred.
  
• Previous utilization management experience preferred.
  
• Behaviorial Health experience preferred.
  

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 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.antheminc.com. Anthem 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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Aetna IncLouisville, KY

Apply Now

• Maintains oversight of functions in multiple service centers, including claim payments, claim rework, member or provider inquiries, billing, enrollment, accounts receivable, and/or implementation services.
  
• Executes strategic and operational plans in support of business segment customer services objectives and initiatives.
  
• Sets business area priorities, allocates resources and develops plans for multiple related teams.
  
• Ensures all critical service metrics and operational results are achieved.
  
• Leads multiple managers, highly specialized professional staff or significant outsourced operations.
  
• Oversees the operations of multiple service centers in different locations handling a customer service function, which may include claims, member or provider services, billing, enrollment, accounts receivable and implementation services.
  
• Oversees operating systems including policies and procedures, operating structure, and information flow across multiple service centers.
  
• Directs implementation of service standards for each location to ensure delivery of quality-focused, consistent cost effective service and administration.
  
• Analyzes operational practices for effectiveness and practicality, while creating a culture which is innovative in its approach to solutions.
  
• Establishes a clear vision aligned with company values; sets specific challenging and achievable objectives and action plans; motivates others to balance customer needs, budgets, and business success.
  
• Develops an organization that attracts, selects, and retains high caliber, diverse talent able to successfully achieve or exceed business goals; builds a cohesive team that works well together and across other business segment functions.
  
• Effectively and proactively manages to budget, analyzing and acting upon financial variances from plan by identifying additional cost saving strategies.
  
• Leads and builds high performance teams across units by providing leadership, mentoring and coaching in achieving understanding of the voice of the customer.
  
• Accountable for leading staff in accordance with Aetna’s standards of leadership excellence.
  
• Monitors and evaluates service center operational plans ensuring customer service standards are maintained during facility shutdowns (anticipated or unanticipated) and during business activity transfers between locations.
  
• Coordinates major plan modifications necessitated by unanticipated business or technology developments.
  
• Develops and implements business strategies to provide accurate and proactive customer service to members, plan sponsors and brokers aligned to service center.
  
• Provides operational support for market management of plan sponsors, members and network providers.
  
• Ensures compliance outcomes are included in all plans and goals.
  
• Demonstrated negotiation skills.
  
• Multiple years proven leadership experience setting strategic direction and influencing change that resulted in quantifiable positive outcomes.
  
• Proven strong leadership skills managing large high performance teams.
  
• Experienced working with vendors.
  
• Customer service experience.
  
• Bachelor’s degree in a closely-related field, or equivalent combination of education and experience.
  
• Must be located in Kentucky.
  
• CVS Health requires its Colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, or religious belief that prevents them from being vaccinated.
  
• If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 10 days of your employment.
  
• For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 45 days of your employment.
  
• In some states and roles, you may be required to provide proof of full vaccination before you can begin to actively work.
  
• Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.
  
• If you are unable to be fully vaccinated due to disability, medical condition, or religious belief, you will be required to apply for a reasonable accommodation within the first 10 days of your employment in order to remain employed with CVS Health.
  
• As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated.
  
• In some states and roles, you may be required to have an approved reasonable accommodation before you can begin to actively work.
  
• If your request for an accommodation is not approved, then your employment may be terminated.
  
• Preferred: Healthcare experience and an advanced degree.
  
• We seek fresh ideas, fresh opinions, a diversity of experiences, and a dedication to service that will help us better meet the needs of the many people and businesses that rely on us each day.
  
• Our high-energy and client-focused colleagues work hard every single day to make a positive difference in the lives of our customers.
  
• Aetna is an Equal Opportunity, Affirmative Action Employer
  
• Advanced degree preferred.
  
• Bachelor’s degree or equivalent experience required.
  
• At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health.
  
• We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused.
  
• Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
  
• We are committed to maintaining a diverse and inclusive workplace.
  
• CVS Health is an equal opportunity and affirmative action employer.
  
• We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status.
  
• We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
  

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Location: Company:

 
 

Apply for this job **Provider Network Analyst Medicaid MCO experience**Location: Dublin, OHPrimary Job Function: Provider NetworkID**: 21798**Job Brief**Must have Managed Care, Medicaid, Claims, Configuration, Excel Access. Pivot Charts, Analytics.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:**+ The primary purpose of the job is to be responsible for the maintaining current provider data and provider reimbursement set up, and to address provider/state inquiries as it relates to claim payment issues.+ Develops the Pricing Agreement Templates (PAT) for all provider reimbursement set up.+ Ensure that provider payment issues submitted by Provider Network Management or any other source are validated, researched and resolved within established SLA timeframes .+ Serves as the subject matter expert in State specific health reimbursement rules and provider billing requirements and as liaison to the Enterprise Operations Configuration Department.+ Maintain a current working knowledge of processing rules, contractual guidelines, state/Plan policy and operational procedures to effectively provide technical expertise and business rules.+ Participate in encounter rejection reconciliation activities.+ Responsible for the analysis of provider reimbursement and updating codes and fee schedules for current reimbursement to providers.+ Participate in Provider Reimbursement medical policy and edit reviews.+ Requests/runs queries to identify root causes of claim denials, incorrect payments and claims that are not correctly submitted for payment.+ Act as the resource to other departments by developing and managing work plans which document the status of key relationship issues and action items for high profile providers .+ Ensures ongoing provider data accuracy through regular reconciliation of the state provider master file, provider rosters, and audits.+ Validate potential recovery claim project activities.+ Maintain tracking system of operational issues, progress, and status.+ Performs other related duties and projects as assigned.**Education/Experience:**+ Required Associate’s Degree or equivalent experience.+ 2+ years of claims analysis experience in a healthcare environment.+ 1-2 years Medicaid. Also Managed Care or related experience preferred.+ Required Claims processing and Provider Data Maintenance knowledge.+ Required understanding of and experience related to healthcare claims payment configuration process/systems and its relevance/impact on network operations required.+ Billing and coding experience a plus.+ Strong with MS Excel, Access, Word, MS Access, MSOffice, Pivot Charts, Analytics.+ Ability to focus on technology and business issues, as well as, communicate appropriately with both technology and business experts.**Note: Presently all of our AmeriHealth Caritas Family of Companies associates are working remotely due to the Pandemic. This role/department will be transitioning to the Dublin, OH location when it is safe to return to the office at:** **5525 Parkcenter Circle Dublin, OH 43017.****Key words: Managed Care, Medicaid, Claims, Configuration, Excel Access. Pivot Charts, Analytics.**EOE Minorities/Females/Protected Veterans/Disabled Apply for this job

 

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This is a 100% Remote Project.

NCDHHS 675742: NC Department of Health and Human Services (DHHS) Information Technology Division (ITD) seeks an IT Quality Manager for the Medicaid Enterprise System (MES) Portfolio. This role is 100% remote.

This is a management position and will serve a part of the core leadership team. Staff supervision is an integral component of the role. This role is 100% remote and candidates across the US are encouraged to apply.

The primary purpose of the Quality Manager (QA Manager) is to coordinate and oversee all program quality functions and oversee all NC Medicaid program reviews. The QA Manager is responsible for assuring program quality standards are developed and implemented and standards are evaluated fairly and consistently. This position verifies all program review deliverables are provided by the timeframes requested and follows up to provide additional information as requested by program reviewers. The Quality Manager is also responsible for working with program staff and management to ensure that all aspects of quality assurance deliverables adhere to and are aligned with state and federal program expectations.

The Quality Manager will be responsible for ensuring that this large, complex program of up to fifteen (15) projects is operating optimally and producing high quality outcomes and deliverables on all levels. This means that the Quality Manager will need to establish systems to monitor and report program performance on both the project and program levels. In order to do so, this role will oversee a team Quality Leads that also drive the development of the program processes, partnering with process owners and other key stakeholders. The Quality Leads will also report on the fifteen different projects in a Quality Dashboard that the Quality Manager will develop.

The Quality Manager is also responsible for supporting development of a Program Maturity Roadmap that incorporates Continual Improvement concepts, which will also incorporate Agile Transformation leveraging the Scaled Agile Framework (SAFe) methodology, and Scrum as relevant.

The Quality Manager will be responsible to stand up processes to gather PMO quality metrics that measure quality of PMI and Agile deliverables, process adherence, and templates – and then report them in a Tableau dashboard.

The Quality Manager will set up systems to evaluate program artifacts and adherence to processes. This will include providing direction and guidance to the Quality Leads on how to most effectively evaluate and report on project and program level quality.

The Quality Manager will be an expert in Visio or other process documentation software, and will have excellent facilitation skills. The Quality Manager will also have expert knowledge of PMI processes, methodology, and best practices, as well as Agile (Scrum and SAFe are ideal) methodology. The Quality Manager will also ideally be familiar with ITIL and minimally have ITIL Foundations certification. Six Sigma certification is also considered a strong asset.

The Quality Manager will ideally have extensive experience in both traditional ‘waterfall’ project management and agile project management. Experience in IT and healthcare project management is strongly desired. This role is expected to be a Subject Matter Expert in program and project organization, and can work independently in mocking up process designs based on best practices combined with program institutional knowledge. Experience in vendor management and outsourcing environments is also an asset, as this program will be establishing processes to manage a complex IT outsourced environment with many vendors, which is a substantial change for the organization. Therefore, Organizational Change Management (OCM) experience is also strongly preferred as the program matures and grows. The ideal candidate also is an expert in crafting high quality project and program documentation based on their expert knowledge of PMI and project management processes.

QA / Program Review Management

o Creating, updating and maintaining quality performance reporting and communicate performance trends to program management.

o Identifying trends and overseeing projects to lead continuous improvement and problem-solving efforts to improve quality

o Aggregating and analyzing quality data and recommending methods for improving product and service quality, design and/or business processes.

o Monitoring, identifying, and analyzing performance metrics in order to provide constructive feedback, maintain high-service levels, and increase production system efficiency.

o Coordinating with NC Medicaid PMO and NC Medicaid O&M to ensure all program review findings are identified, tracked. Ensuring a mitigation plan is in place with defined dates for resolution.

o Reviewing product history and lessons learned from design validation sources, current production quality, and warranty data to identify and drive preventive measures to ensure optimal quality of each project as it is implemented.

o Acting as liaison to federal program reviewers and State and DHHS Project Monitoring Oversight teams.

o Following up with management on all exceptions and corrective actions pertaining to quality reviews by staff.

o .

o Assisting in determining the State’s future goals for MITA (technology framework and business processes) by leading meetings with internal stakeholders and vendors to map the State’s Replacement MMIS processes to the “To-Be” MITA 3.0 maturity levels.

o Monitoring the CMS Information Technology Systems certification exercise which is heavily reliant on MITA compliance for the technical architecture for deployed IT systems.

o Conducting gap analyses of the As-Is operations and To-Be environments to identify appropriate actions needed to reach target program maturity levels

o Documenting the program maturity roadmap which maps over time the program’s actions to reach target program maturity levels.

o Perform crosswalks to evaluate the State Business Process Model’s (BPM) alignment with or deviation from the CMS-defined MITA BPM.

o Ensure the utilization of industry best practices for compliance with CMS and State-defined performance standards.

o Additionally, this resource may interface with Division Leadership and other DHHS Subject Matter Experts (SME) as required to complete the work.

Communication

• Communicating effectively with internal and external clients.
  
• Providing timely communication to project team management on any potential issues.
  
• Communicating and consulting within Division, project stakeholders and within technical community.
  
• Meeting monthly with NC Medicaid PMO and NC Medicaid O&M to review risks and mitigation plans.
  
• Working with leadership to assure that the program is operating in accordance with contract expectations and providing reports and recommendations for sustained or improved quality management.
  
• Communicating clearly goals, processes, and procedures to representatives with varied skill sets (business staff, technicians, managers, etc.).
  
• Using outstanding written communication skills.
  

Supervision, Organizing and Directing Work:

• Providing direction on work activities in accordance with organization goals; monitoring the work of team members to ensure timely, cost-effective completion of work.
  
• Identifying required skill sets by role and development of a skills list for the team. Creating and maintaining a resource plan document that forecasts and plans resource needs for the team and communicating the resource plan to management.
  
• Providing the team with constructive feedback as it pertains to performance; developing and fostering an effective team; and encouraging leadership and professional growth in team members as appropriate.
  
• Developing and maintaining a productive working relationship with external entities, project sponsors, vendors, and other staff.
  
• Supervising and evaluating subordinate staff; motivating team members and facilitating team meetings, identifying and analyzing problems, plans, tasks, and solutions; monitoring team budget (if applicable) and ensuring proper use of assets.
  

Technical Leadership

• Provide leadership in development of IT project related documentation including RFP, RFI, RFQ, etc.
  
• Supports the CMS Information Technology Systems certification exercise which is heavily reliant on MITA compliance for the technical architecture for deployed IT systems.
  
• Conducts gap analyses to identify appropriate actions needed to reach target maturity levels.
  
• Articulates requirements, makes recommendations for process and business flows, develops consensus on requirements, and documents requirements via approved process and templates
  
• Work with DHHS leadership to develop and analyze proposals for IT project initiatives and make recommendations regarding business solutions and alternatives.
  
• Exhibits working knowledge of hardware, software, application, and systems engineering.
  
• Plans for and executes projects for federal and state compliance.
  
• Participates in pricing and technical reviews of proposals, bids, contracts, etc.
  
• Reviews and provides recommendations on IT expenditures.
  
• Developing project issue and risk memos as needed
  
• Knowledge of IT governance and operations.
  
• Knowledge of financial modeling as it pertains to IT investment
  

Professional Development

• Participate in selection, management, guidance, and training of project staff for assigned initiatives
  
• Demonstrated experience in utilizing tactical thinking/decision making skills as well as strategic thinking
  
• Mentoring and developing project team members.
  
• Demonstrated experience of continuing education training and activity development
  

This is a management position and will serve a part of the core leadership team. Staff supervision is an integral component of the role.

Clipped from: https://tarta.ai/j/Lsas4H4BKrWuRFkYAdql-director-of-medicaid-and-health-services-in-helena-montana-at-state-of-montana?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

This position is the Medicaid and Health Services Executive Director. The position is responsible for medical, rehabilitative, and mental health service programs by overseeing the following Department Divisions: Developmental Services Division, Health Resources Division, Senior and Long Term Care Division, and Addictive and Mental Disorders Division. Included are seven institutional treatment and long term care facilities: Montana Chemical Dependency Center, Intensive Behavior Center, Montana Mental Health Nursing Care Center, Montana State Hospital, and three Montana Veterans Homes. The position directly supervises four division administrators and two Medicaid managers, and indirectly supervises approximately 1400 FTE.

The position also carries the designation of the State Medicaid Director.

Major Duties or Responsibilities:

A. Executive Leadership, Supervision and Management

Provides executive leadership to the agency as member of Senior Management Team that consists of the agency Director, three Executive Directors, fourteen division Administrators, Chief Legal Counsel, Chief Human Resources Officer, Chief Information Officer, Chief Finance Officer and Public Information Officer.

Establishes business plans and objectives and administers, coordinates and evaluates programs and activities.

Implements the agency management plan. Ensures that directives are implemented by agency divisions.

Executes the authority of the agency Director.

Advises the Director concerning agency policies, programs, and activities.

Provides overall policy direction and control and monitors the status of programs to ensure agency goals and objectives are accomplished.

Evaluates existing management systems for improvement. Identifies and promotes needed organizational changes.

Coordinates at the executive level with other state or local agencies, provider groups, and federal agencies to maintain cooperative relationships and solve problems.

Serves as the State Medicaid and CHIP Director. Is the primary state contact for the federal Center for Medicare and Medicaid Services. Approves state plan amendments and waivers.

May act as agency Director in his or her absence.

B. Directs and Controls Division Operations

Provides direction and review of matters dealing with, general administration, contracting, operating procedures, and non-routine or sensitive program matters.

Establishes, directs and monitors implementation of division and program priorities. Ensures resources, including staffing, are available and effectively utilized to insure achievement of goals.

Negotiates and settles disputes between divisions or between the agency and the public.

Oversees health service policy matters of division and major program budgets. Directs policy reviews to verify compliance with agency and federal objectives.

Oversees legislative activity. Reviews legislation and fiscal notes, lobbies, testifies and ensures legislative requests are completed. Liaises with the legislature.

Work with the Departments Chief Innovation Officer to better align clinical and non-clinical supports to address social determinants of health, improve beneficiary outcomes

Liaise with tribal leadership to ensure transparency and coordination on efforts to improve the health outcomes of native populations.

C. Human Resource Management

Determines organizational structure for areas responsible.

Delegates authority to subordinate executive and management employees and holds them responsible for performance of their divisions.

Provides oversight, direction, consultation and assignment of duties to management and executive level employees.

Ensures subordinate compliance with state and Department human resource rules, regulations, policies, and collective bargaining agreements.

Oversees collective bargaining and labor management issues.

Physical and Environmental Demands: Typical office environment. Regular travel throughout the state, with or without advance notice, 10%. Stress and long hours are common to the position.

Minimum Qualifications (Education and Experience):

Bachelors degree in business, public, hospital, or health administration; human services; health-care services; or a directly-related field.

Five or more years of senior-level management and supervisory experience of large programs with substantial staff and budgets.

Other combinations of related education and experience may be considered on a case-by-case basis if the applicant has an unrelated bachelors degree.

Preferred: Specific experience with Medicaid, CHIP or Medicare.

Experience in a medical field such as nursing, mental health, addiction, etc. Experience in health facility administration.

Clipped from: https://www.linkedin.com/jobs/view/68024191-medical-health-care-program-analyst-at-state-of-florida-2914851142/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Requisition No: 569993


Agency: Agency for Health Care Administration


Working Title: 68024191 – MEDICAL HEALTH CARE PROGRAM ANALYST


Position Number: 68024191


Salary: $1,574.93 Bi-Weekly


Posting Closing Date: 02/18/2022


This is an exciting opportunity to help shape the quality of health care in Florida. The Agency for Health Care Administration (AHCA) is the State of Florida agency responsible for oversight of the Medicaid program. The Medicaid program provides low-income families and individuals with access to health care. If you have a desire to use your talent and skills at an organization that provides critical services to millions of individuals and families across the state, AHCA invites you to apply to become an essential member of our team. As one of Florida’s leading state agencies, AHCA’s diverse workforce community of more than 1,400 employees is proud of its efforts to serve the people of Florida.


We are seeking to hire a Medical Healthcare Program Analyst who desires to work to enhance the delivery of health care services through the Florida Medicaid Program. This position requires a candidate who is creative, flexible, innovative, and who will thrive in a fast-paced, team-based work environment.


This is a complex analytical position in the Bureau of Medicaid Fiscal Agent Operations (MFAO) within the Agency for Healthcare Administration (AHCA).


This position is responsible for coordinating provider terminations with the Office of the Medicaid Director, the Bureau


of Medicaid Program Integrity and MFAO’s Provider Enrollment Unit.


The incumbent will evaluate Florida Department of Health practitioner and AHCA facility licensure actions and


coordinate appropriate Medicaid action.


The incumbent will conduct investigations surrounding Medicaid provider types that are considered “high risk” for


fraud.


The incumbent will review providers that are potentially excluded from federal healthcare programs.


The incumbent will utilize Business Objects programs to prepare ineligible Medicaid provider reporting to Medicaid contracted


health plans.


The incumbent will assist in evaluating incoming referrals of a fraud-based nature received from AHCA-contracted


health plans, other AHCA bureaus and other agencies.


The incumbent will provide research assistance and Medicaid enrollment/eligibility information to other state agencies


and AHCA bureaus.


The incumbent shall possess and maintain up-to-date knowledge concerning the Florida Medicaid Program, including


the Florida Medicaid Management Information System (FMMIS), pertinent state and federal laws and administrative


rules and codes governing state and federal healthcare programs, Medicaid provider handbooks and Medicaid provider


enrollment procedures.


The incumbent shall be responsible for replying to denied, terminated, and suspended Medicaid providers or


applicants utilizing standard/approved language that protects and supports the Florida Medicaid Program.


Incumbent shall possess outstanding organizational and formal writing skills.


The Incumbent will be hired at the base rate of $1574.93 Bi-weekly


AHCA Offers An Excellent Array Of Benefits, Including

• Health insurance
  
• Life insurance
  
• Dental, vision and supplemental insurance
  
• Retirement benefits
  
• Vacation and sick leave
  
• Paid holidays
  
• Opportunities for career advancement
  
• Tuition waiver for public college courses
  
• Training opportunities
  
  
  

For more information about the Bureau of Medicaid Fiscal Agent Operations, please visit our website at http://ahca.myflorida.com/Medicaid/index.shtml.


Join us at the Agency for Health Care Administration in fulfilling our mission to provide “Better Health Care for all Floridians.”


Knowledge, Skills, And Abilities

• Ability to determine work priorities
  
• Ability to communicate effectively
  
• Ability to establish and maintain effective working relationships with others
  
• Ability to understand and apply applicable rules, regulations, policies and procedures relating to management
  
• analysis activities
  
• Ability to collect, evaluate and analyze data
  
• Ability to develop alternative recommendations, solve problems, documents and other activities relating to the
  
• improvement of management practices
  
• Ability to organize data into a logical format for presentation in reports, documents, and other written material
  
• Ability to utilize problem-solving techniques and make decisions independently
   
  

Minimum Qualifications Requirements


Two years of professional experience in a health or rehabilitation program involving program or policy planning


and development, program research or evaluation, finance, statistical analysis, accounting, auditing or budget


analysis.


Licensure, Certification, Or Registration Requirements


N/A


CONTACT: DEBBIE KELLEY (850) 412-3449


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://us.melga.com/job/2022-02-09_443259c7184cc184b9254c905d650e9d?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Source: Lensa – Since 15 hours ago

MetroPlus Health Plan Bridgeport, Ct Full Time

About NYC Health + Hospitals

MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview:

The primary goal of the Care Manager is to optimize members’ health care and delivery of care experience with expected cost savings due to improved quality of care. This is accomplished through engagement and understanding of the member’s needs, environment, providers, support system and optimization of services available to them. Care Manager is expected to assess and evaluate member’s needs, be a creative, efficient and resourceful problem solver. In collaboration with the members’ care team, a plan of care with individualized goals and interventions is developed, implemented and outcomes evaluated.

Job Description

• Address member’s problems and needs: clinical, psychosocial, financial, environmental
  
• Provide services to members of varying age, risk level, clinical scenario, culture, financial means, social support, and motivation
  
• Engage members in a collaborative relationship, empowering them to self-manage their physical, psychosocial and environmental health to improve and maintain lifelong well being
  
• Prepare member-oriented plan of care with member, caregivers, and health care providers, integrating concepts of cultural sensitivity and privacy practices
  
• Participate in interdisciplinary rounds
  
• Ensure plans of care have individualized goals and interventions
  
• Communicate plan of care to Primary Care Physician
  
• Address gaps in care with the member and provider
  
• Address members social determinants of health issues
  
• Link members to available resources
  
• Provide care management support during Transitions of Care
  
• Ensure member/caregiver understanding as it relates to language barriers, stress reaction or cognitive limitations/barriers
  
• Train member on relevant chronic diseases, preventive care, medication management (medication reconciliation and adherence), home safety, etc.
  
• Provide Complex care management including but not limited to; ensuring access to care, reducing unnecessary hospitalizations, and appropriately referring to community supports
  
• Advocate for members by assisting them to address challenges and make informed choices regarding clinical status and treatment options
  
• Employ critical thinking and judgment when dealing with unplanned issues
  
• Maintain knowledge of Chronic Conditions and use job aids as a guidance
  
• Maintain accurate, comprehensive and current clinical and non-clinical documentation in DCMS, the Care Management System
  
• Comply with all orientation requirements, annual and other mandatory trainings, organizational and departmental policies and procedures, and actively participate in evaluation process
  
• Maintain professional competencies as a Care Manager
  
• Other duties as assigned by Manager
  

Minimum Qualifications

• Background: Registered Nurse, Bachelor’s Degree in Nursing required
  
• An equivalent combination of training, educational background, and experience in related fields such as hospital, home care, ambulatory setting and educational disciplines. Prior experience in Care Management in a health care and/or Managed Care setting preferred
  
• Proficiency with computers navigating in multiple systems and web- based applications
  
• Confident, autonomous, solution driven, detail oriented, high standards of excellence, nonjudgmental, diplomatic, resourceful, intuitive, dedicated, resilient and proactive
  
• Strong verbal and written communication skills including motivational coaching, influencing and negotiation abilities
  
• Time management and organizational skills
  
• Strong problem-solving skills
  
• Ability to prioritize and manage changing priorities under pressure
  
• Must know how to use Microsoft Office applications including Word, Excel, and PowerPoint and Outlook.
  
• Ability to proficiently read and interpret medical records, claims data, pharmacy, lab reports and prescriptions required
  
• If needed, ability to travel within the MetroPlus service area to participate in facility visits, community events, home visits or other community meetings, including conferences.
  
• Registered Nurse or LMSW/LCSW with current NYS license
  

Immediate hiring

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Clipped from: https://us.trabajo.org/job-1373-20220209-bfc5acac40c37c664674bc4c90f520af?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Found in: S US – 21 hours ago

Nashville, United States NTT DATA Services Full time

Req ID: 176353 

NTT DATA Services strives to hire exceptional, innovative and passionate individuals who want to grow with us. If you want to be part of an inclusive, adaptable, and forward-thinking organization, apply now.

We are currently seeking a Medicaid Eligibility Subject Matter Expert (SME) to join our team in Nashville, Tennessee (US-TN), United States (US).

The Medicaid Eligibility Subject Matter Expert (SME) will work directly with the client’s operations staff to assist with ongoing system enhancement work.  This includes but is not limited to participation in definition, design, testing and implementation of changes in each of the system releases. This Medicaid Eligibility SME will be a valued member of the client’s Business Services Support team. The Medicaid Eligibility SME will work collaboratively with the client and other vendors on the client’s projects and initiatives. The Medicaid Eligibility SME will provide valuable business analysis services and subject matter expertise through consultation with the client. The Medicaid Eligibility SME will integrate seamlessly with the client team to ensure that business needs are met by managing and driving change using knowledge and experience. 
Job Responsibilities Include:
a.    Work collaboratively with the Member Services team leveraging their Eligibility business operations skills and expertise as well as their systems implementation experience, to improve the operational efficiency of the team and increase the quality of the systems enhancements and changes that go into production.
b.    Participate in identifying any operational impacts created by proposed system changes and recommend modifications to business workflow and processes. 
c.    Participate in requirements definition and design, business workflow development, design, and improvement, the review of system integration test case and results, and the review of user acceptance test case and results.
d.    Participate in implementation planning and execution activities, such as operational readiness tests, parallel tests, and beta tests.
e.    Develop and execute Eligibility Business Operations Test Cases as part of the User Acceptance phase for each system release. 
f.    Collaborate with the Enterprise Testing Management Office (eTMO) to ensure that testing standards and processes are maintained as the Eligibility Business Operations Test Cases are executed and defects are identified.
g.    Employee is expected to undertake any additional duties as they are assigned by their manager. 

Basic Qualifications:
•   Minimum 5 years’ recent experience in the health and human services eligibility determination 
•    Minimum 1 year of experience interpreting complex eligibility determination rules, policy, and processes
•    Minimum 3 years’ business experience working on large complex system implementation and/or enhancement projects
•    Minimum 1 year of experience interacting with vendors and third parties effectively to meet commitments and milestones 
•    Minimum1 year experience developing process flows
•    Must be able to travel to Nashville, Tennessee 50% of the time, post COVID-19 restrictions

Preferred Skills:
•    Bachelor’s degree or equivalent experience
•    Ability to work independently and manage work to a defined schedule
•    Strong written and verbal communication skills
•    Experience conducting meetings and making presentations
•    Strong problem-solving and customer service skills
•    Team player and a consistent, dependable performer with an excellent work ethic, flexible “can-do” attitude, and a results-driven commitment to success
•    Ability to apply industry best practices and future state/federal mandates to existing systems
•    Excels at using quantitative data to drive recommendations and decisions

About NTT DATA Services

NTT DATA Services is a global business and IT services provider specializing in digital, cloud and automation across a comprehensive portfolio of consulting, applications, infrastructure and business process services. We are part of the NTT family of companies, a partner to 85 % of the Fortune 100.

NTT DATA Services is an equal opportunity employer and considers all applicants without regarding to race, color, religion, citizenship, national origin, ancestry, age, sex, sexual orientation, gender identity, genetic information, physical or mental disability, veteran or marital status, or any other characteristic protected by law. We are committed to creating a diverse and inclusive environment for all employees. If you need assistance or an accommodation due to a disability, please inform your recruiter so that we may connect you with the appropriate team.

Clipped from: https://www.linkedin.com/jobs/view/medicaid-business-solution-and-operation-leader-work-remote-at-cnsi-2913343037/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Introduction


At CNSI, we strive to be the market leader and most trusted partner for innovative and transformative technology-enabled solutions that improve health outcomes and reduce costs. We’re passionate about helping our clients improve the health and well-being of individuals and families. We succeed when our clients succeed.


Overview


CNSI is looking for a Medicaid Business Solutions and Operations leader to join our growing Government Health and Human Services team to kick off 2022!


As a Medicaid Solution & Business operations leader, you will play a key role in leading, developing and solutioning large complex MMIS deals within the government healthcare market to provide expert Medicaid fiscal agent business operations leadership and direction to the Business Development, Operations and Technology teams across CNSI

• Position will work remotely. Central or Eastern Time zones preferred
  
  
   
  

Responsibilities

• Develops business case justifications and cost/benefit analyses for business operations spending and initiatives, providing support to the budget process as needed
  
• Ensures that the business operations team identifies risks and issues, escalates them to senior management, and assists in developing mitigation strategies
  
• Advise and drive emerging trends and industry practices in the Medicaid services and business operations field
  
• Partners with customers and internal/external stakeholders to develop long-term strategies and solutions
  
• Manage the technical development and content for Requests for Proposal (RFP), evaluates solutions, defines governance, and supports technology delivery management process
  
• Define customizations to standard products and solutions to meet specific client requirements
  
• Develops project scoping planning and basis of estimates for CNSI engagements
  
  
   
  

Requirements

• 8+ years Medicaid industry experience with focus on the MMIS market
  
• 10+ years of experience in solution or operation leadership role, preferably in large complex organizations leading matrixed teams
  
• Possesses recognized expertise in the Medicaid fiscal agent services business operations field, including emerging trends and industry practices
  
• Proven ability as a hands-on leader to build and develop action-oriented teams to achieve common goals
  
  
   
  

About Us:


At CNSI, we strive to be the market leader and most trusted partner for innovative and transformative technology-enabled solutions that improve health outcomes and reduce costs. We’re passionate about helping our clients improve the health and well-being of individuals and families. We succeed when our clients succeed.


Innovation and commitment to our mission are core to our DNA. And through our shared values, we foster an environment of inclusion, empowerment, accountability, and fun! You will be offered a competitive compensation and benefits package.


CNSI is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, sexual orientation, gender identity, marital status, genetic status, family responsibilities, protected veteran status or any other status protected by applicable Federal, state, or local law. We are proud of our diversity and encourage all qualified applicants to apply.