Category: Curator- Job Hunter

 
 

 
 

The Ohio Department of Medicaid (ODM) is committed to improving the health of Ohioans and strengthening communities and families through quality care. In 2020, ODM introduced a new vision for Ohio’s Medicaid program — one that strengthens Ohio’s future and ensures everyone has the chance to live life to its full potential.

Today, more than 90 percent of Ohio Medicaid members are supported by managed care organizations. During the year ahead, ODM will begin implementing a new vision for care; focusing on the individual, a strong partnership among MCOs and the department, and supporting specialization in addressing critical needs.

A program that puts the individual first

Adopting Governor DeWine’s philosophy of service to Ohioans, ODM embarked on an aggressive effort to redesign its managed care program. The goal is to provide more personal, holistic care and supports for millions of Ohioans served by Medicaid. Listening to feedback from more than 1,100 individuals and organizations we identified five procurement goals that would put the individual front and center of Medicaid’s program and policy decisions. They are:

• Emphasize a personalized care experience
  
• Improve care for children and adults with complex behavioral health needs
  
• Improve wellness and health outcomes
  
• Support providers in better patient care
  
• Increase program transparency and accountability
  

UNLESS REQUIRED BY LEGISLATION OR UNION CONTRACT, STARTING SALARY WILL BE SET AT STEP 1 OF THE PAY RANGE

Office: Policy

Bureau: Health Plan Policy

Classification: Medicaid Health Systems Administrator 1 (PN 20087220)

Job Overview:

The Ohio Department of Medicaid (ODM) is seeking an experienced healthcare administrator to join the Policy Management and Development (PMD) team to assist with developing, implementing, and managing general provisions of the Ohio Medicaid program. This team is responsible for developing and implementing Ohio Administrative Code (OAC) rules that apply broadly such as those concerning provider agreements and credentialing, payment, coordination of benefits, program integrity, alternative payment models, telehealth, claim submission, prior authorization, electronic data interchange and national standards, and HIPAA compliant healthcare transactions. As a PMD healthcare administrator, your responsibilities will include:

• oversight of ODM’s provider credentialing policy including updates to Ohio Administrative Code (OAC), Medicaid state plan, and Medicaid Management Information System (MMIS)
  
• evaluating & assessing program needs & requirements for improving oversight and enforcement of general provisions
  
• completing updates to OAC rules and the state plan, managing the filing process, and implementing necessary changes across the agency to support operations
  
• ensuring policies comply with federal & state regulations, rules & laws
  
• assisting in the development and maintenance of the state MMIS
  
• evaluating and analyzing policies related to the design and regulatory oversight of general Medicaid provisions
  
• acting as a policy liaison and collaborating with other areas of ODM, sister state agencies, and/or external stakeholder groups
  
• communicating with stakeholders and developing instructional or educational materials to support implementation of programs and policies
  
• responding to inquiries from internal and external stakeholders
  

The preferred candidate will be detail-oriented, have strong critical thinking and problem solving skills, the ability to manage multiple priorities, and display great organizational and time management abilities.

Completion of graduate core program in business, management or public administration, public health, health administration, social or behavioral science or public finance; 12 mos. exp. in the delivery of a health services program or health services project management (e.g., health care data analysis, health services contract management, health care market & financial expertise; health services program communication; health services budget development, HMO & hospital rate development, health services eligibility, health services data base analysis).

Or 12 months experience as a Medicaid Health Systems Specialist, 65293.

Note: education & experience is to be commensurate with approved position description on file.

• Or equivalent of Minimum Class Qualifications for Employment noted above.
  

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Position Description


Mathematica applies expertise at the intersection of data, methods, policy, and practice to improve well-being around the world. We collaborate closely with public- and private-sector partners to translate big questions into deep insights that improve programs, refine strategies, and enhance understanding using data science and analytics. Our work yields actionable information to guide decisions in wide-ranging policy areas, from health, education, early childhood, and family support to nutrition, employment, disability, and international development. Mathematica offers our employees competitive salaries, and a comprehensive benefits package, as well as the advantages of being 100 percent employee owned. As an employee stock owner, you will experience financial benefits of ESOP holdings that have increased in tandem with the company’s growth and financial strength. You will also be part of an independent, employee-owned firm that is able to define and further our mission, enhance our quality and accountability, and steadily grow our financial strength. Learn more about our benefits here.


Mathematica is searching for professionals with experience generating insights from data on Medicaid policy and programs at either the state or federal level. In particular, we are looking for individuals who can apply data analytics to support current and emerging work across any number of areas related to monitoring and improving Medicaid programs such as: Value-based purchasing and alternative payment models, enrollment trends, measures of delivery and quality of services for beneficiaries, and to discern outcomes of innovative programs and policies.


The successful candidate will join our group of over 400 health policy professionals, including staff with degrees in data analytics, public health, public policy, economics, behavioral or social sciences, economics, and other relevant disciplines. We offer our employees a stimulating team-oriented work environment, competitive salaries, and a comprehensive benefits package, as well as the advantages of employee ownership.


Duties Of The Position

• Participate actively and thoughtfully in multidisciplinary teams, drawing on your past experience with Medicaid programs
  
• Help conduct research and technical assistance projects on topics related to state and federal Medicaid policy
  
• Apply rigorous analytic thinking to the collection and interpretation of quantitative data including analysis of Medicaid administrative data
  
• Bring creative ideas to the development of proposals for new projects
  
• Author project reports, memos, technical assistance tools, issue briefs, and webinar presentations
  
• Contribute to the growth, expertise, and institutional knowledge of staff working in the Medicaid area
  
  
  

Qualifications


Position Requirements:

• 3-8 years of experience working in health policy or health research, with a substantial portion of that time related to some aspect of the Medicaid program at the state or federal level
  
• Masters or doctoral degree or equivalent experience in data analytics, public health, public policy, economics, behavioral or social sciences, economics, or other relevant disciplines
  
• Demonstrated ability at modeling program outcomes would be ideal
  
• Strong foundation in quantitative methods and a broad understanding of health policy issues
  
• Excellent written and oral communication skills, including an ability to explain observations and findings to diverse stakeholder audiences including program administrators and policymakers
  
• Demonstrated ability to provide task leadership and coordinate the work of multidisciplinary teams
  
  
  

Strong organizational skills and high level of attention to detail; flexibility to lead and manage multiple priorities, sometimes simultaneously, under deadlines


To apply, please submit a cover letter, resume, writing sample, and salary expectations at the time of your application.


Available Locations: Washington, DC; Princeton, NJ; Cambridge, MA; Woodlawn, MD; Ann Arbor, MI; Chicago, IL; Oakland, CA; Seattle, WA; Remote


This position offers an anticipated annual base salary of $90,000 – $140,000. This position may be eligible for a discretionary bonus based on company and individual performance.


Various federal agencies with whom we contract require that staff successfully undergo a background investigation or security clearance as a condition of working on a project. If you are assigned to such a project, you will be required to obtain the requisite security clearance.


We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

 
 

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Steward Health Care Network (SHCN) takes pride in its community-based care model, which drives value-added tools and services to our communities, patients, physicians, and hospitals across the continuum of care. In addition, Steward Health Care Network promotes care coordination and collaboration within the network in order to provide high-quality, efficient care to patients. With Steward in the community, all residents can be sure that there is a world-class doctor close to where they live.

The network is also responsible for the implementation and execution of our managed care contracts, medical management services, quality improvement programs, data analysis, and information services.

Position Purpose: Under the direction of the National Senior Director for Government Quality Programs, the Manager, Medicaid ACO Performance Programs oversees all aspects of performance initiatives, vendor management, and project planning for the Medicaid ACO. This role will lead key business initiatives aimed at ensuring operational efficiencies, meeting budgeted and contractual performance targets, and coordinating between cross functional business partners (e.g., Care Management, Pharmacy and Medicaid business unit) to drive quality performance outcomes for the Medicaid ACO. The role will assume a variety of tasks including, but not limited to, developing, and executing project and implementation plans, reporting on progress towards key business objectives, continuous QI/PI research and reporting, and vendor management.

• Develops and maintains Performance Programs strategic plan for the Medicaid ACO, ensuring that strategies are made with consideration of quality improvement, utilization management, care retention, and are developed using internal performance data, industry standards, and published literature
  
• Responsible for planning, coordinating, implementing, and overseeing strategies and tactics to support Performance Operations team with the goal of improving quality and financial performance. Provides project management support to QM, which may include creating and monitoring tracking mechanisms and monitoring improvement initiatives
  
• Oversees implementation and management of Performance Operations vendors and associated contracts for the Medicaid ACO. Ensures compliance of vendor obligations and optimizes use of vendor services and capabilities by Performance Operations team members
  
• Develops and maintains Performance Programs dashboard to identify opportunities for improvement, growth, and continued success, using competitive intelligence and industry research as applicable. Using data, evidence-based techniques, and business (contractual) priorities, identify top opportunities to improve performance measure rates and communicate these in a clear and timely fashion to leadership
  
• Creates plans, systems, and methods to support integration of new opportunities into the department’s workflow
  
• Oversees Medicaid ACO quality measurement, reporting and audits, including HEDIS, CAHPS, and custom state measures. Through data and analysis, evaluates impact of performance programs, and uses results to identify improvement and enhancement opportunities
  
• Project manages all aspects of collection of hybrid performance measure data and submission of this data to regulatory bodies in an accurate, complete, and timely fashion. Identify and implement opportunities to collect this data year round
  
• Manages quality improvement audit cycle, including project plans, training curriculum, and quality control of auditor’s work
  

Education / Experience / Other Requirements

Education:

• Bachelor’s degree required
  
• Master’s Degree preferred
  

Years of Experience:

• Four (4) + years of experience in health care quality focused roles that included medical record audits and/or performance metric i.e., HEDIS, Stars, or similar
  
• Significant experience in quality measurement, HEDIS, interpretation of claims data, medical record review
  

Specialized Knowledge:

• Strong computer skills, i.e., using various software, including intermediate Excel skills (sort, filter, reformat data, etc.)
  
• Strong analytic skills/ability to translate complicated data into useable information, including analysis of practice variation
  
• Successful experience managing complex projects beginning to end with accountability for outcomes, demonstrated organizational and project management skills to manage complex projects through effective planning, tracking, and resource allocation to meet business objectives and timelines
  
• Strong leadership and management skills; self-directed Ability to generate creative solutions
  

Steward Health Care is an Equal Employment Opportunity (EEO) employer. Steward Health Care does not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.

 
 

Clipped from: https://shcnjobs.steward.org/manager-medicaid-aco-performance-programs/job/17537789?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

The Office of Attorney General Keith Ellison — one of Minnesota’s largest public law offices and recently recognized as a Star Tribune 2021 Top Workplace — has a clear mission: we help Minnesotans afford their lives and live with dignity, safety, and respect. We are a dynamic group of dedicated professionals who could all work elsewhere but choose public service as a calling, and we are actively building an internal culture that supports that calling.


The Office is currently accepting applications from attorneys to serve within the Medicaid Fraud Control Unit (MFCU).


Responsibilities: Attorneys in the MFCU serve primarily as criminal prosecutors working to protect the integrity of Minnesota’s medical assistance program and ensure accountability for those who defraud it. Attorneys prosecute complex criminal cases against health care providers in State district court. The division also prosecutes abuse, neglect, and financial exploitation of vulnerable adults upon referral from county attorneys’ offices, many of whom come from lesser populated counties. The division responds to criminal appeals and post-conviction petitions as well. Finally, attorneys in the division may also handle a limited civil case load of False Claims Act cases.


Qualifications

• Graduation from a law school accredited by the ABA;
  
• Licensed to practice in the State of Minnesota or ability to obtain licensures within 90 days of hire;
  
• An interest in handling criminal prosecution;
  
• Excellent research and writing skills;
  
• Ability to work on lengthy, complex, document-intensive cases;
  
• Ability to travel to counties throughout the state;
  
• Proven ability to multitask by managing an active caseload and meeting tight deadlines;
  
• Proven ability to contribute positively to a team; and
  
• Proven ability to work in an inclusive, creative, and collaborative work environment.
   
  

Preferred Qualifications

• Criminal litigation experience as a prosecutor or public defender.
  
  
  

Why Work For Us:
We offer a great benefits package! The State of Minnesota offers a comprehensive benefits package including low cost medical and dental insurance, employer paid life insurance, short and long term disability, pre-tax flexible spending accounts, retirement plan, tax-deferred compensation, generous vacation and sick leave, and 11 paid holidays each year.


Public service with this office may qualify applicants to have part of their student loans forgiven under a federal student loan forgiveness program for state government employees. (Visit www.studentaid.ed.gov/sa/repay-loans/forgiveness-cancellation/public-service for more information.)


Application Information: Interested applicants must apply online through the State of Minnesota Careers website, which is the State’s official application and hiring site. The deadline for applications is November 1, 2021.

• Go to www.mn.gov/careers;
  
• Apply for posting number 49883;
  
• Ensure to attach a cover letter with a writing sample of up to five pages.
  
  
  

If you have any questions about the application process, please contact K.C. Moua at kc.moua@ag.state.mn.us or (651) 757-1279.

Note: The Attorney General’s Office greatly encourages, celebrates and values diversity. It is an equal opportunity employer which does not discriminate on the basis of race, creed, color, national origin, religion, sex, marital status, sexual orientation, gender identity, age, disability, or military status. If you need reasonable accommodation for a disability, please call K.C. Moua at (651) 757-1279 or (800) 627-3529 (Minnesota Relay).

 
 

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State Medicaid Data Warehouse Analytics SME

Are you a Medicaid Management Information System (MMIS) subject matter expert with technical/functional State Medicaid Data Warehouse Analytics experience? Do you want to help us transform the Medicaid market as it embraces modularization and we help our clients create a new future for Medicaid technology?

Work you’ll do

 

• Work on implementing MMIS or Medicaid Data Warehouse for State Medicaid Agencies
  
• Provide system level expertise across multiple computing platforms and technologies and work to influence direction around information management at the Enterprise Level
  
• Work with program managers, state directors and other key stakeholders, build sustainable relationships with key stakeholders responsible for information and performance management in client’s organization
  
• Organize knowledge transfer to clients
  
• Develop and manage vendor relationships
  
• Present in workshops for client education
  
• Manage team s on a data warehousing engagement
   
  

The team

Our Health Technology team implements repeatable solutions to solve our government clients’ most critical health technology related issues. We advise on, design, implement and deploy solutions focused on government health agencies “heart of the business” issues including claims management, electronic health records, health information exchanges, health analytics and health case management.

Our clients seek a fresh perspective on how to leverage reusable, interoperable and flexible solutions that will enable them to reduce costs, improve health outcomes and respond to public health crises. Professionals will use their deep health, government and technology consulting experience to strategically help solve our client’s technology challenges.

Qualifications

Required:

3+ years of experience within a Consulting or Health Technology environment

State MMIS experience

Data Warehouse experience

Bachelor’s Degree from an accredited College or University

Must be legally authorized to work in the United States without the need for employer sponsorship, now or at any time in the future

Desired:

Experience within Medicaid Management Information systems (MMIS), Medicaid or Commercial Health Care claims, Provider Management and/or Eligibility data

Experience implementing a data warehouse for State Medicaid Agency

Experience with one of more of the following: SQL/PLSQL, ETL, Cognos, R, Python, Tableau, QlikView, Power BI, Business Objects

Experience in designing, analyzing, supporting and developing data warehouse objects, data quality processes, fact and dimension tables, logical and physical database design, data modeling, reporting process metadata and ETL processes.

Experience working in Cloud based environment (AWS or Azure)

Healthcare Data Analytics

Oral and written communication skills, including presentation skills (MS Visio, MS PowerPoint

Ability to travel

 

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Job Description

The Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD) is the state agency that focuses solely on policies, programs, and services for people with mental health challenges, substance use disorders, intellectual and developmental disabilities, or any combination of these.

As Georgia’s public safety net, DBHDD operates six field offices and five hospitals throughout the state within three program areas: behavioral health, developmental disabilities and hospital services.

The main office for DBHDD is located in downtown Atlanta.

Job Description

Job Title: Medicaid Eligibility Specialist

Pay Grade: H

Job Summary:

The Medicaid Eligibility Specialist (MES) position is part of DBHDD’s SSI/SSDI Outreach, Access, and Recovery (SOAR) Program.

SOAR is a federal program designed to increase access to SSI/SSDI for eligible adults and children who are experiencing or at risk of homelessness and have a serious mental illness, medical impairment, and/or a co-occurring substance use disorder.

The MES will focus on helping people with behavioral health disorders attain healthier and more productive lives by making successful application for Social Security Administration benefits as a stepping stone.

This position will be dedicated to working with individuals referred to and participating in the Georgia Housing Voucher Program which provides permanent supportive housing to adults experiencing homelessness who have severe and persistent mental illness.

Access to benefits is a major factor in whether a household can find affordable housing and whether they can maintain housing stability once housed.

The position will coordinate with community provider agencies working with GHVP applicants and enrollees, as well as the office that oversees GHVP, the Office of Supportive Housing.

The position is responsible for initial outreach to the providers in the community, DBHDD Hospitals, ongoing outreach services, and completion of the application process, and/or technical assistance as needed to ensure completion of the application.

This position reports to the Budget Compliance & Medicaid Manager.

Note: This position is community based and will require moderate to extensive local travel.

Essential Responsibilities include:

Completion of the SSI/SSDI application according to established policies and procedures of the project.

Hand deliver/electronic transfer of all needed application forms and information.

Collection of existing medical evidence, including visiting treating sources.

Coordination and communication with social workers and case managers.

Linkage and coordination with SSA, referral to and linkage with other needed services, e.g., housing, health care (physical and mental), other supportive services as needed.

Coordination with representative payee service.

Ongoing follow-up as needed to ensure individuals are not lost to services.

Utilizing substantial independent judgment in prioritizing and problem-solving issues.

Organizing and recording data consistent with project goals and priorities.

Participate in trainings related to SOAR.

Facilitate training classes as needed or requested.

Provide technical assistance to community providers, hospital and regional offices.

Assists qualified mentally and physically disabled homeless individuals to access SSI, SSDI, and mental benefits.

Responsible for maintaining timely and thorough charting/record keeping on each client and assisting in monitoring performance and outcome measures.

Complete or assist in completing monthly reports when necessary.

Utilize interview and engagement skills in order to complete multiple assessments and collect evidence to substantiate the client’s claim.

Compile all the medical records, assessments and observations into a medical report that summarizes how their disability impacts their life, their activities of daily living and their ability to work.

Collaborate with the disability adjudicators to help advocate for the client’s approval.

Attend relevant community meetings to represent the department.

Other duties as assigned.

Preferred Qualifications:

Preference will be given to candidates, who in addition to meeting the qualifications listed above possess the following:

Completion of the National 4-day SOAR “Train the Trainer” training conducted by the authors of the SOAR curriculum and Policy Research Associates.

Experience in completing SSI/SSDI applications using SOAR strategies for homeless individuals with mental illness.

Demonstrate two (2) years experience and knowledge in working with homeless persons and veterans with mental illness in accessing mainstream resources including Social Security Disability Benefits.

Basic computer skills and able to access and use web-based technology, including the online SSA application

Experience in collecting data to track performance outcomes.

Benefits

In addition to a competitive salary & benefits, GA Department of Behavioral Health and Developmental Disabilities is part of a statewide initiative called Total Rewards that seeks to attract and retain employees by supplementing their base pay and benefits with programs designed to improve the quality of their work environment and lead to greater job satisfaction and work/life balance.

Eligible employees are offered generous benefits, including health and dental insurance; retirement and savings plan options; and paid holidays, vacation and sick leave.

For more information, visit https://dbhdd.georgia.gov/benefits

Employment Requirements

To ensure the safety and wellbeing of our employees, individuals and communities we serve, certain positions within DBHDD may require evaluations, vaccinations, professional licensure and certifications.

Licenses must be current and enable providers to practice within the State of Georgia.

The following are a listing of evaluations and vaccinations that may be required for employees, including those not involved with direct care:

Drug Screening

TB Evaluation

Annual Influenza*

Limited exemptions may be made for documented medical contraindications or religious beliefs that object to vaccinations.

DBHDD is an Equal Opportunity Employer

It is the policy of DBHDD to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law.

Due to the volume of applications received, we are unable to provide information on application status by phone or e-mail.

All qualified applicants will be considered but may not necessarily receive an interview.

Selected applicants will be contacted by the hiring agency for next steps in the selection process.

This position is subject to close at any time once a satisfactory applicant pool has been identified.

FOR THIS TYPE OF EMPLOYMENT, STATE LAW REQUIRES A NATIONAL AND STATE BACKGROUND CHECK AS A CONDITION OF EMPLOYMENT.

Bachelor’s degree in a related field from an accredited college or university OR Associate’s degree from an accredited college or university AND One year of related experience OR High school diploma or GED AND Three years of related experience OR Two years of experience at the lower level Economic Support Cons 1 (SSP050) or position equivalent.

 
 

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Job Description


Independently provide advanced, diversified and confidential administrative support requiring broad experience, skill and knowledge of organization operations, policies and practices. Initiates correspondence, resolves complex inquiries, coordinates complex meetings and travel arrangements. Coordinates Manger’s time commitments both internally and externally. Has authority to handle most issues in Manager’s absence.


Manages workflow for incoming items to ensure that issues are directed to the appropriate area (particularly in Manager’s absence). Monitors status of delegated items to ensure closure. Majority of work involves confidential business material.


Opens, reads, organizes, prioritizes and responds to mail or directs to appropriate area for response. Monitors status to ensure closure.


Authorized to manage calendar, making all changes independently, for both internal and external executive time commitments. Manages daily calendar to ensure that priorities are accomplished and unplanned items are address appropriately.


Organizes and maintains files of supervisor’s correspondence, records etc. following up on pending matters.


Develops and monitors budget for cost center(s). Prepares complex budget reports.


Leads special projects Authorized to approve expenditures up to assigned dollar amount.


In Manager’s absence, has authority to handle most issues.


Drafts correspondence for Manager’s final approval


Required Qualifications


5+ years executive administrative support experience


Strong communication and interpersonal skills


Detail oriented and organized


Strong calendar management skills


Computer literate with the ability to learn new software applications quickly


Intermediate to advanced level abilities with Microsoft Office products and Adobe products


Ability to organize and lead projects and perform multiple tasks in a busy environment


Flexible and ability to adapt readily to changing circumstances


COVID Requirements


COVID-19 Vaccination Requirement


CVS Health requires its Colleagues in certain positions 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, pregnancy, 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 30 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 60 days of your employment. 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, pregnancy, or religious belief, you will be required to apply for a reasonable accommodation within the first 30 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. If your request for an accommodation is not approved, then your employment may be terminated.
  Preferred Qualifications

  Noted above

  Education

  Associate’s degree or equivalent work experience.

  Business Overview

  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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Medicaid – Medicare: Healthcare Fraud Investigator – REMOTE

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 – Medicare Healthcare Fraud Investigator, also called, Program Integrity Action Analyst II will primarily be responsible for performing investigations, site visits once evaluations and developments of complaints determine an investigation is warranted.

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:

• Perform evaluation and development of complaints to determine if referral as an investigation is warranted
  
• Conduct independent reviews resulting from the discovery of situations that potentially involve fraud or abuse
  
• Utilize basic data analysis techniques to detect aberrancies in Medicare and Medicaid claims data, and proactively seeks out and develops leads received from a variety of sources (e.g., CMS, OIG, 1-800-MEDICARE, and fraud alerts)
  
• Review information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare and Medicaid policies and initiates appropriate action
  
• Make potential fraud determinations by utilizing a variety of sources such as internal guidelines, Medicare and Medicaid provider manuals, Medicare and Medicaid regulations, and the Social Security Act
  
• Compile and maintain documentation and information related to investigations, cases, and/or leads
  
• Participate in onsite audits in conjunction with investigation development
  
• Develop and prepare potential fraud alerts and program vulnerabilities for submission to CMS; share information on current fraud investigations with other Medicare and Medicaid contractors, law enforcement, and other applicable stakeholders
  
• Perform other duties as assigned by PI Supervisor or PI Manager that contribute to task order goals and objectives
  

Requirements:

• At least 1 year of experience in program integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information, and making appropriate decisions.
  
• Excellent oral, written and verbal skills
  
• Ability to work independently with minimal supervision
  
• Knowledge of statistics, data analysis techniques, and PC skills are preferred
  
• Experience with Microsoft Excel preferred
  

Educational Qualifications:

• At a minimum, a high school diploma, with preference given to those candidates who have successfully completed college or technical degree programs related to the position (e.g., criminal justice, statistics, data analysis, etc.)
  
• 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.*

 
 

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The Medicaid Project Manager 2 manages all aspects of a project, from start to finish, so that it is completed on time and within budget. The Medicaid Project Manager 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

 
 

 
 

**Responsibilities**

 
 

 
 

The Medicaid Project Manager 2 designs, communicates, and implements an operational plan for completing the project, monitors progress and performance against the project plan and takes action to resolve operational problems and minimize delays.

 
 

 
 

+ Identifies, develops, and gathers the resources to complete the project.

 
 

 
 

+ Prepares designs and work specifications; develops project schedules, budgets and forecasts; and selecting materials, equipment, project staff, and external contractors.

 
 

 
 

+ Communicates with other operational areas in the organization to secure specialized resources and contributions for the project.

 
 

 
 

+ Conducts meetings and prepare reports to communicate the status of the project.

 
 

 
 

+ Sets priorities, allocates tasks, and coordinates project staff to meet project targets and milestones. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.

 
 

 
 

+ Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

 
 

 
 

**Required Qualifications**

 
 

 
 

+ Bachelor’s degree or equivalent experience.

 
 

 
 

+ 3 – 5 years’ experience managing cross functional medium to large scale projects in a fast paced environment.

 
 

 
 

+ Ability to manage stakeholders and hold them accountable for deliverables.

 
 

 
 

+ Comfortable working on new projects with limited knowledge/expertise of the content and be able to learn quickly in order to effectively manage the implementation.

 
 

 
 

+ Proficiency in facilitating meetings and communicating effectively with project stakeholders up to and including senior level leadership.

 
 

 
 

+ 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.

 
 

 
 

+ 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.

 
 

 
 

**Preferred Qualifications**

 
 

 
 

+ Six Sigma and / or Project Management Institute certification.

 
 

 
 

+ Strong communication, presentation and leadership skills.

 
 

 
 

+ Advanced MS Office experience (MS Project, Visio, and Excel).

 
 

 
 

+ Flexible and adaptable dealing with ambiguous situations.

 
 

 
 

+ Prior experience in the health solutions industry.

 
 

 
 

**Additional Information**

 
 

 
 

+ **Typical Work Days/Hours:** Monday – Friday; Eastern Standard Time (EST)

 
 

 
 

+ **Travel:** up to 10%

 
 

 
 

**Interview Format**

 
 

 
 

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

 
 

 
 

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

 
 

 
 

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

 
 

https://tarta.ai/j/-E-OcHwBPV406l6XS_hL-medicaid-operations-project-manager-2-remote-us-in-birmingham-al-at-humana?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Job Summary:

Manages client relationships and acts as a trusted advisor, thought leader and general manager to grow the business through sales Develops a client-centered agenda (plan), improves the financial quality of the account [s] (grow), harnesses innovations to meet contractual commitments (deliver) and provides the leadership that aligns teams and holds members accountable for results (lead).  Provides pan-company leadership working across company and with the customer as one unified company account team.  Use of this job family is restricted:  must own an account, sub-region/region P & L.

Responsibilities:

• Unique mastery and recognized authority on relevant subject matter knowledge including technologies, theories, or techniques
  
• Develops strategy and set functional policy and direction.
  
• Acts as a functional manager within area of expertise but does not manage other employees as a primary job function.
  
• Leads large, cross-division functional teams or projects that affect the organizations long-term goals and objectives.
  
• Contributes to the development of innovative principles and ideas
  
• Successfully operates in the most complex disciplines, in which the company must operate to be successful.  Provides highly innovated solutions
  
• Routinely exercises independent judgment in developing methods, techniques and criteria for achieving objectives. 
  
• Delivers Account  Business Plan (ABP), Account Financial Plan (AFP), and Account Operating Plan (AOP)
  
• Leads, coordinates, and manages the long-term, consultative, client relationship to become the client’s trusted advisor
  
• Establishes and manages, a program to achieve client service excellence
  
• Meets or exceeds financial commitments
  
• Delivers on company’s contractual commitments, technical or process innovations
  Enforces a change management mechanism for requests   outside the agreed scope
  
• Ensures a strong governance framework and meeting cadence within company and between company and the customers
  
• Leads all employees who provide services to the client, either directly or indirectly
  

Education and Experience:

• Bachelor’s Degree or equivalent, MBA or equivalent preferred
  
• 10-12 years’ experience in account leadership roles such as sales, delivery or business management
  
• At least five (5) years previous account management experience in managing State Medicaid Management Services
  
• Previous experience with a Medicaid Management System or with major operations-related components of an Medicaid Management System or other large healthcare systems and an ongoing relationship management with a large client.
  
• Experience working in a matrixed  environment
  
• Experience in IT industry required  and vertical industry preferred
  
• P & L, sales and risk management skills required
  

Knowledge and Skills:

• General Management Skills
  
• Consultative sales skills
  
• Financial Acumen
  
• Knowledge of IT Industry, including trends and competitors
  
• In depth knowledge of vertical industry
  
• Change Management skills
  
• Strong communication skills
  

 
 

https://jobs.gainwelltechnologies.com/job/Any-city-Account-General-Manager-State-Medicaid-Management-Services-NV-99999/789611700/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic