Category: MM Curator

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Aetna, an Ohio Medicaid contractor, accused of denying kids care in Pennsylvania

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More details released from the PA court case against Aetna suggest an extensive issue of assigning kids to PCPs known to not be in network.

 
 

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

The following article was originally published in the Ohio Capital Journal and published on News5Cleveland.com under a content-sharing agreement.

COLUMBUS, Ohio—In a case that could have implications for Ohio, a Pennsylvania whistleblower is accusing Aetna of making it impossible for the parents of some kids on Medicaid to find doctors. The insurer then pocketed money from the state for services not rendered, the suit alleges.

Aetna denies the charges.

Recent Stories from news5cleveland.com

The case is relevant here because the Ohio Department of Medicaid in April awarded a $1 billion contract to Aetna to implement OhioRISE, an ambitious new program meant to coordinate care for 60,000 children with complex behavioral needs.

The Pennsylvania allegations, which were unsealed last month in federal court in Pittsburgh, might cast doubt on whether the company will live up to its promises in the OhioRISE program.

The allegations also add to questions of conflict and bias concerning Ohio’s procurement this year of the OhioRISE contract and six others for $22 billion worth of Medicaid managed care. Together, the contracts are meant to reshape the way the Ohio Medicaid department delivers care to 3 million people.

The Ohio Department of Medicaid was asked to comment on the Pennsylvania suit a week ago. As of Tuesday, it hadn’t responded other than to acknowledge that it had been asked for comment.

For its part, Aetna parent company CVS Health denies the accusations.

“Aetna places the highest priority on the health and wellbeing of its members, and we provide access to quality care through a comprehensive provider network, including in Pennsylvania,” spokesman Bob Joyce said in an email. “Plaintiff’s allegation that Aetna has network adequacy deficiencies across the country is irresponsible and unrelated to the (U.S. Justice Department’s) investigation.

“Aetna denies the allegations in the complaint, and intends to vigorously defend itself should (the whistleblower) choose to move forward with her non-intervened complaint. Aetna is pleased that after reviewing all of the evidence, the government chose not to participate in the lawsuit.”

The case was filed under the False Claims Act, which encourages people with knowledge of government rip-offs to blow the whistle by giving them a portion of the money recovered.

While it’s accurate that the federal government declined to intervene in the suit, the federal government is said to intervene — or take over — in only about 20% of such cases.

And in an Aug. 25 filing, the Justice Department notified the court that the federal government would continue to be listed as a plaintiff and pointed out that the case can only be dismissed if Attorney General Merrick Garland consents to it. The filing also asked U.S. Magistrate Judge Cynthia Reed Eddy to unseal the complaint, which she did the following month.

Serious claims

The Pennsylvania whistleblower, Carol Wessner, accused Aetna Better Health of Pennsylvania of shrinking its network of doctors for kids on Medicaid and then lying to the Pennsylvania Department of Health about it.

Aetna hired Wessner as a “quality management nurse consultant” in 2013. Her primary task was to investigate why such a high percentage of Aetna’s child patients were missing their Early and Periodic Screening, Diagnostic and Treatment appointments. The doctor visits, required by Medicaid since 1967, are intended to catch developmental and other health issues as early as possible.

Wessner claims that she discerned a pattern. Aetna officials contended that kids were missing appointments because providers were discriminating against them, but she found that time and again, those providers weren’t in Aetna’s network.

Wessner “never encountered an (Aetna pediatric doctor) who discriminated against children on (Aetna) Medicaid,” the suit says. “Rather, many of the (doctors) to whom children were assigned (i) were not contracted with (Aetna); (ii) were dead; (iii) were out of state; or (iv) did not see children at all.”

Many of the physicians to whom Aetna claimed to assign children wouldn’t be likely to pass even superficial scrutiny, Wessner said.

“… children, including two-year-old boys, were assigned to gynecologists, hospitalists and vascular surgeons,” the lawsuit says, referring to a provider group that Aetna listed as in its pediatric network. Aetna “also had wrong addresses, phone numbers and affiliations for the (primary care providers) at this site.”

Wessner also provided possible evidence that Aetna was deliberately shrinking its network while telling a different story to Pennsylvania Medicaid officials.

She said that on May 7, 2014, she was in a meeting with a Philadelphia public health official when the official was handed a note from Aetna. The company was notifying the city’s department of health that it was terminating its contracts with all eight of the agency’s City Health Centers, the suit says.

Yet by “February 2015 — almost a year later — (Aetna) still had 491 children enrolled with the department,” the lawsuit says. “Some were enrolled as recently as Feb. 1, 2015.”

Wessner claims that Philadelphia was far from the only agency in which Aetna terminated contracts with providers while continuing to tell state Medicaid officials that its child clients were enrolled with the agencies’ doctors. Her lawsuit says Aetna took similar actions with at least six other health systems, in some cases assigning children to doctors within the systems even after terminating their contracts.

In the case of the Reading Health Physicians Network, the lawsuit claims that in September 2016 — almost two years after Aetna had terminated its contract — the company still assigned 1,127 of its child clients to doctors there. Seven hundred thirty six of them hadn’t had their federally required diagnostic exams in at least a year, it said.

The lawsuit says money was the motive for all this.

Aetna “misrepresented its network adequacy by including providers (Aetna) knew were inaccessible in order to gain new Medicaid enrollees that would increase (Aetna’s) per-member/per-month payment from Medicaid.”

Payback?

Wessner claims she was retaliated against for repeatedly flagging problems to her superiors, including Aetna Better Health of Pennsylvania CEO Jason Rottman.

She said her supervisor, Alice Jefferson, in 2015 told her to stop sending written reports and make them verbally instead. In 2016, Wessner was removed from her job investigating kids’ missed checkups. Then in 2018, she was terminated.

Regardless of the outcome of the case, it adds to questions about the companies hired as part of Ohio’s Medicaid reforms this year.

Aetna’s parent company, CVS, has long been accused of gouging Ohio Medicaid for prescription drugs — a charge the corporation denies. UnitedHealth has faced similar accusations and is being sued over fraud claims by Attorney General Dave Yost. Yet it was one of six giant corporations to be awarded huge managed-care contracts in this year’s procurement.

Yost in March sued another of those corporations, Centene, and it paid out $88 million in June to settle them.

When the Ohio Medicaid department undertook its procurement process, it set it up in a way that didn’t allow evaluators to consider previous bad acts by the companies applying. Now Mercer, the consultant that facilitated the process, won’t say whether any of the successful bidders are also its clients.
 

 
 

Clipped from: https://www.news5cleveland.com/news/state/aetna-an-ohio-medicaid-contractor-accused-of-denying-kids-care-in-pennsylvania

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Wyoming Senate squash look at Medicaid expansion during special session

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Lawmakers voted 21 to 8 to not introduce an expansion bill in the Senate.

 
 

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

A Healthy Wyoming rally for Medicaid expansion at the Nicolaysen Art Museum in September. (Gregory Hirst)

CASPER, Wyo. — The Wyoming Senate voted against introducing a bill to expand Medicaid in Wyoming during the legislature’s special session on Monday, October 27.

Sen. Cale Case (Fremont County), asked that the Senate approve Senate File 1011, which is known as the Medical Treatment Opportunity Act.

Case said that expanding Medicaid could benefit 25,000 people in Wyoming. He said the would be “mostly females that are working in this state.”

Article continues below…

“They are people that serve you breakfast, clean your hotel rooms. They have children and this would be a great thing for them,” Case said.

He added that the bill was sponsored by the Joint Revenue Interim Committee, noting that this made it different from most of the legislation proposed for consideration during the special session.

The Senate defeated the bill on a vote of 8-21 during its floor session on Monday afternoon. That vote was as follows:

  • Ayes: BALDWIN, CASE, FURPHY, GIERAU, KOST, ROTHFUSS, SCHULER, WASSERBURGER
  • Nays: ANDERSON, BITEMAN, BONER, BOUCHARD, COOPER, DOCKSTADER, DRISKILL, ELLIS, FRENCH, HICKS, HUTCHINGS, JAMES, KINSKEY, KOLB, LANDEN, MCKEOWN, NETHERCOTT, PERKINS, SALAZAR, SCOTT, STEINMETZ
  • Excused: PAPPAS

A recent poll conducted by New Bridge Strategy found that 66% of Wyoming registered voters support expanding Medicaid. That includes 98% of Democrats in the state, 64% of Independents and 58% of Republicans.

The Medical Treatment Opportunity Act would direct the Wyoming Department of Health, the state’s insurance commissioner and the governor to negotiated with the Centers for Medicare and Medicaid Services (CMS) to amend the state’s Medicaid plan and expand eligibility.

Under the 2010 Affordable Care Act, 90% of the cost of expansion would be paid by the federal government and Wyoming would pay 10%. The Wyoming Department of Health estimates expanding coverage would cover an estimated 24,000 (between 13,000 and 38,000) residents, and net the state $34 million in General Fund savings over the next biennium. The WDH estimates that 60% who would benefit from expansion are currently employed.

Proponents of Medicaid expansion have been working to push the legislature to again consider expanding Medicaid after a similar effort failed during the 2021 General Session. During that session, the House of Representatives passed a measure to expand Medicaid on a vote of 32-28 but the bill stalled out on a 2-3 vote in the Senate Labor, Health and Social Services Committee.

The group Healthy Wyoming held vigils across the state in September to raise awareness about projected savings for the state under expansion and to share stories of people who have suffered and died without health care.

The Casper contingent met at the Nicolaysen Art Museum on September 17 to hear from health care providers, legislators, and people directly affected by the issue. 

“This issue is a matter of life or death,” said Healthy Wyoming advocate Andrew Schneider in his remarks. He said people who can’t afford to go to the doctor allow chronic conditions, including mental illness, to “linger and worsen.” They also skip cancer screenings and other preventative measures and can’t budget for both prescriptions and food.

Linda Jones spoke about her friend and neighbor Earl, who died three years ago. She said Earl worked a steady job at Walmart until he slipped on the ice and injured his knee, and lost his job while recovering.

Without insurance, he was unable to achieve a full recovery, became afflicted with gout, and sold a cherished Camero to pay bills. His health declined rapidly and he was eventually found dead in his home.

“It was a difficult thing to watch another person be in so much pain and not know how to help,” Jones said. “At the time, we didn’t think there was anything that could be done about Earl not being able to see a doctor. … Now I know if that if our state had expanded Medicaid, Earl could have gotten the health care he needed.”

“He wanted to get better; he wanted to work to provide for himself.”

Critics have cited concerns that expansion has led to significant cost overruns and decreased profit margins for hospitals in other states. They also worry that the federal government could change its match rates, leaving Wyoming “on the hook” for a greater percentage of costs.

 
 

Clipped from: https://oilcity.news/wyoming/legislature/2021/10/27/wyoming-senate-squash-look-at-medicaid-expansion-during-special-session/

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Democrats Mull Dropping Expanded Medicare, Medicaid in Unity Bid

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Dems need to cut the $3T price tag of the wishlist in half.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

Two significant elements of Democrats’ ambitious health agenda, expanding Medicare and Medicaid, face an uphill battle after a key party moderate signaled his opposition Monday.

Sen. Joe Manchin (D-W.Va.) said Monday he doesn’t want to expand Medicare benefits without first protecting the rest of the program from insolvency later this decade.

He also rebuffed legislation to extend coverage to millions of Americans in states that have refused to expand their Medicaid programs.

Extending federally funded coverage to people in the 12 non-expansion states effectively amounts to a penalty for states such as his that have paid a portion of growing their own safety nets, Manchin told reporters.

“For states that held out to get rewarded with 100% that’s not fair,” he said.

 
 

Anna Moneymaker/Getty Images

Sen. Joe Manchin (D-W.Va.) leaves a meeting at the office of Sen. Kyrsten Sinema (D-Ariz.) on Oct. 21, 2021, as Democrats sought consensus on trimming President Joe Biden’s spending legislation.

Expanding the two public health insurance programs were significant, and pricey, elements of the once-$3.5 trillion spending package Democrats (H.R. 5376) are hoping to rally around as soon as this week. Manchin said he wants to cut the total spending down to $1.5 trillion.

Supporters of expanding Medicare’s benefits to include dental, hearing, and vision coverage have been trying to save the provision from cuts or elimination.

The White House has suggested the spending package include $800 vouchers seniors could use to pay for dental services, Rep. Pramila Jayapal (D-Wash.) told reporters last week. Jayapal and other progressives have pushed to add the three new coverage areas to Medicare’s list of defined benefits.

Vouchers would leave many seniors without sufficient coverage and could disappear in coming years, supporters of expanding Medicare say.

“This cannot be a half-hearted attempt to throw a token at the problem,” said Frederick Isasi, executive director of Families USA, a health advocacy organization that’s been aligned with Democrats on defending the Affordable Care Act.

Manchin, who has been negotiating the terms of the spending package directly with President Joe Biden at times over the past few weeks, said he wants to first shore up Medicare’s finances.

“You’ve got to stabilize that first before you do an expansion,” he said Monday.

Drug Pricing Plan Also Trimmed

Democrats may have to pare back their health agenda to accommodate a narrower attempt to lower the cost of medicines in the U.S.

Party leaders are debating limiting their legislation to empower the government to negotiate for better prices to just drugs that lack exclusivity, meaning only those medicines that could already face competition from a generic or biosimilar version.

Such a change would limit how much a drug price negotiation proposal would reduce government spending on medicines. The drug pricing provisions of the spending package have long been meant to offset the cost of the health agenda.

Rep. Scott Peters(D-Calif.), who has opposed broad negotiating power, wrote legislation that also didn’t apply to many new drugs that have patent protections. He said recently his bill would reduce government spending by at least $200 billion, compared with the $458 billion in reduced spending expected from Democrats’ signature negotiation legislation (H.R. 3)

Leslie Dach, chairman of the Democratic-aligned Protect Our Care, told reporters Monday that exempting medicines that don’t have competitors would “basically gut the negotiation promise” Democrats had made.

“That is the key that unlocks lower prices,” Dach said.

Read more: Democrats Set to Scale Back Drug-Price Ambitions in Biden’s Bill

To contact the reporters on this story: Alex Ruoff in Washington at aruoff@bgov.com; Erik Wasson (Bloomgerg News) in Washington at ewasson@bloomberg.net

To contact the editor responsible for this story: Robin Meszoly at rmeszoly@bgov.com

 
 

Clipped from: https://about.bgov.com/news/democrats-mull-dropping-expanded-medicare-medicaid-in-unity-bid/

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Portman, Finance Committee Republicans raise concerns with improper Medicaid payments

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14 US Senators are asking CMS head Lasure to explain the plan to get a handle on the surging improper payment rate.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

WASHINGTON, D.C. – U.S. Senator Rob Portman (R-OH), along with the other 13 Senate Finance Committee Republicans, sent a letter to the Centers for Medicare & Medicaid Services (CMS) highlighting concerns with the rising rate of improper payments in Medicaid, in anticipation of the next Medicaid Payment Error Rate Measurement (PERM) audit.

The November 2020 report found improper payments totaled over $86.5 billion — over 21 percent — mostly driven by eligibility errors. The letter further calls for enhanced program integrity measures and state-by-state analysis to ensure beneficiaries receive the services they are entitled to without wasting taxpayer dollars.

“One of the most common eligibility errors often occurs when failing to verify information provided by the applicant, including income. Failure to properly verify that applicants are eligible for the program, especially to this extent, harms the nation’s taxpayers and takes resources away from those who are eligible and who truly need the program,” said the senators.

“There is concern that the November 2020 improper payment rate estimate of 21.4 percent was unrealistically low because the eligibility reviews excluded one-third of states.

“Congress needs complete and updated information about the improper payment rate in Medicaid as well as the corresponding drivers of this problem. We understand that the essential work on the 2021 CMS improper payment report has concluded, and drafts of the report have been completed. While state and Federal responses to COVID-19 halted some payment and eligibility reviews in 2020, this work is too vital to remain paused when the consequences are so dire,” continued the senators.

Full text of the letter can be found below.

Dear Administrator Brooks-LaSure:

As some in Congress consider proposals to expand the Medicaid program by potentially half a trillion dollars over the next decade, it is vital that both Senators and Members of the House of Representatives have accurate information about how the program is using taxpayer resources. Every November, the Centers for Medicare and Medicaid Services (CMS) releases estimates of improper payment rates for programs within its jurisdiction. The November 2020 report showed that the Medicaid improper payment rate reached 21.4 percent, with total federal improper payments in the program amounting to $86.5 billion annually. Medicaid’s improper payment rate has significantly increased since the passage of the Affordable Care Act, which dramatically expanded Medicaid. In 2013, the year before the ACA’s Medicaid expansion took effect, the improper payment rate was just 5.8 percent.

According to last year’s report, eligibility errors are the major drivers of the increased Medicaid improper payment rate. According to CMS, “Eligibility errors are mostly due to insufficient documentation to affirmatively verify eligibility determinations or non-compliance with eligibility redetermination requirements.” One of the most common eligibility errors often occurs when failing to verify information provided by the applicant, including income. Failure to properly verify that applicants are eligible for the program, especially to this extent, harms the nation’s taxpayers and takes resources away from those who are eligible and who truly need the program.

There is concern that the November 2020 improper payment rate estimate of 21.4 percent was unrealistically low because the eligibility reviews excluded one-third of states. Since the Obama Administration cancelled eligibility audits from 2014-2017, this year’s forthcoming report will be the first complete assessment of all states since the expansion took effect. Given its more complete nature, the upcoming assessment has the potential to show that the improper payment rate in the program exceeds 25 percent, totaling above $100 billion annually.

Such a high improper payment rate demonstrates that the program requires a stalwart defense to ensure those that are eligible receive the care they need. This rate also raises questions of whether Congressional and regulatory actions have made Medicaid too complicated for the Federal government to properly oversee it, especially given the differing improper payment rates among states. Congress needs complete and updated information about the improper payment rate in Medicaid as well as the corresponding drivers of this problem. We understand that the essential work on the 2021 CMS improper payment report has concluded, and drafts of the report have been completed. While state and Federal responses to COVID-19 halted some payment and eligibility reviews in 2020, this work is too vital to remain paused when the consequences are so dire.

Given the importance of accurate data to inform ongoing policy discussions, by Monday, November 8, we ask that you provide:

The updated improper payment rate in Medicaid;
A breakdown of improper payment rates by state; and
The corresponding estimated total of improper payments from insufficient verification or non-compliance with eligibility requirements.

When asked about this at a June hearing in front of the Senate Finance Committee, Secretary Becerra committed to making available such data. We also request a briefing with Committee Members’ staff, so that Congress can ask informed questions on this important matter.

 
 

Clipped from: https://highlandcountypress.com/Content/In-The-News/In-The-News/Article/Portman-Finance-Committee-Republicans-raise-concerns-with-improper-Medicaid-payments/2/20/73497

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Proposal Research Consultant- Anthem

 
 

Description:

Description

SHIFT: Day Job

SCHEDULE: Full-time

 

Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.  This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America’s leading health care companies and a Fortune Top 50 Company.

 
 

 
 

Location:  Any of the following states:  IN, OH, GA, VA, CA, NV, MO, KY, CT, NH, ME, WI, NY.  The selected candidate must reside within a commutable distance to an Anthem office in any of the above-mentioned states.  

 
 

 
 

The Proposal Research Consultant is responsible for managing subject matter content in the proposal library and related data sources to be used for completing Request for Proposals to accurately present the organization’s capabilities to potential clients. Primary duties may include, but are not limited to:

  • Serves as content expert and key knowledge source for proposal development.
  • Manages the accuracy of library database entries including researching answers and establishing information pipelines with key subject matter experts (SMEs).
  • Disseminates information to the proposal writing staff.
  • Proofreads, edits, and standardizes proposal text. Edits proposal responses for structure, completeness, accuracy, organizational consistency, and appropriateness of content.
  • Researches company websites and other internal and external resources to identify new organizational products and initiatives and engages appropriate SMEs for further information.
  • Improves the efficiency of all aspects of the proposal library process, including proposal submissions, content matter, content verifications, and audits.
  • Provides guidance and training to proposal associates regarding how to effectively search, filter and navigate the database and use the tool, as well as improve the style and quality of proposal responses via new messaging or sales stories.

Qualifications

Minimum Requirements:  Requires a BA/BS degree in a related field or business area and a minimum of 4 years of related experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Qualifications:  Prior healthcare industry experience strongly preferred. Strong technical and custom writing skills, as well as grammatical and editing skills; this includes the ability to write about different brands or products in a unified voice and effectively translate verbiage from SMEs into compelling prose is strongly 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.


Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

 
 

Clipped from: https://anthemcareers.ttcportals.com/jobs/7744338-proposal-research-consultant-medicaid?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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Medicaid Data & Analytics Product Owner Liaison | Accenture

 
 

The Medicaid Data & Analytics Product Owner Liaison (POL) is responsible for product planning and delivery though the product lifecycle. They partner with the State Product Owner (PO) and technology architects to create and sell a compelling vision for the product that will achieve stakeholder objectives. The POL then works with the State PO, project manager, and technology architects to prioritize the product backlog into epics and features that maximize business value. The POL further refines backlog items as needed, participates in Agile Scrum ceremonies, and clarifies business requirements for the Scrum team. The POL operates with limited supervision and must demonstrate excellent time management, work planning, and communication.

Minimum of 4 years Business analysis experience for data and analytics systems development including business process design, requirements gathering, documentation, and testing

Minimum of 4 years Microsoft Office experience including Excel and Word

Minimum of 2 years Working with healthcare claim or encounter data

Minimum of 1 year Work experience as a Product Owner, Product Manager, or related role

Minimum of 1 year Agile Scrum 1 years SQL experience to facilitate analysis and testing Preferred Skills TX Medicaid business and systems knowledge Experience creating queries and reports using SAP Business Intelligence BusinessObjects Previous work experience as a Project Manager Experience developing data warehouse and business intelligence solutions

What We Believe

We have an unwavering commitment to diversity with the aim that every one of our people has a full sense of belonging within our organization. As a business imperative, every person at Accenture has the responsibility to create and sustain an inclusive environment.

Inclusion and diversity are fundamental to our culture and core values. Our rich diversity makes us more innovative and more creative, which helps us better serve our clients and our communities. Read more here

Equal Employment Opportunity Statement

Accenture is an Equal Opportunity Employer. We believe that no one should be discriminated against because of their differences, such as age, disability, ethnicity, gender, gender identity and expression, religion or sexual orientation.

All employment decisions shall be made without regard to age, race, creed, color, religion, sex, national origin, ancestry, disability status, veteran status, sexual orientation, gender identity or expression, genetic information, marital status, citizenship status or any other basis as protected by federal, state, or local law.

Accenture is committed to providing veteran employment opportunities to our service men and women.

For details, view a copy of the Accenture Equal Opportunity and Affirmative Action Policy Statement.

Requesting An Accommodation

Accenture is committed to providing equal employment opportunities for persons with disabilities or religious observances, including reasonable accommodation when needed. If you are hired by Accenture and require accommodation to perform the essential functions of your role, you will be asked to participate in our reasonable accommodation process. Accommodations made to facilitate the recruiting process are not a guarantee of future or continued accommodations once hired.

If you would like to be considered for employment opportunities with Accenture and have accommodation needs for a disability or religious observance, please call us toll free at 1 (877) 889-9009, send us an email or speak with your recruiter.

Other Employment Statements

Applicants for employment in the US must have work authorization that does not now or in the future require sponsorship of a visa for employment authorization in the United States.

Candidates who are currently employed by a client of Accenture or an affiliated Accenture business may not be eligible for consideration.

Job candidates will not be obligated to disclose sealed or expunged records of conviction or arrest as part of the hiring process.

The Company will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. Additionally, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the Company’s legal duty to furnish information.

 
 

Clipped from: https://www.linkedin.com/jobs/view/medicaid-data-analytics-product-owner-liaison-at-accenture-2756299074/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 

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Provider Network Analyst Senior – Medicaid [ Expert User in Facets & SQL ] | AmeriHealth Caritas

 
 

Job Brief


The Provider Network Analyst Sr. will be responsible for being the go to person for research and analyst of provider issues. Experience with claims and billing required. Knowledge of Medicaid market preferred.


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


Responsibilities


Responsible for research and analysis related to provider network issues. Supports new business provider recruitment and contracting or responsible for research and analysis related to provider claims issues. Identifies systematic and procedural issues resulting in processing reports and initiating actions to produce reports. Extracts manipulates, and evaluates accuracy of provider data for new implementations or responsible for ensuring plan stays in compliance with provider contracts.


Gathers complex statistical data analysis to identify financial and non-financial impacts and process and system improvements. Uses provider contract maintenance software to create provider contract templates and creates files associating contract templates and other credentialing forms. Assists with and coordinates configurations and testing and generates new reports as required.


Education/ Experience


  • Bachelor’s Degree preferred or an equivalent education and experience.
  • Facets configuration knowledge preferred
  • Building queries using SQL, MS Access, or other technical analysis tools.
  • 1 to 2 years managed care or related experience.
  • Advanced experience with sophisticated databases with 3 to 5 years analytical experience in the Healthcare industry.
  • Superior analytical skills.
  • Proficiency with Microsoft Office Suite (Word, Excel, Power Point).
  • Full competence in report preparation, layout and design.
  • Ability to plan, organize and handle multiple tasks.
     

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Clipped from: https://www.linkedin.com/jobs/view/provider-network-analyst-senior-medicaid-expert-user-in-facets-sql-at-amerihealth-caritas-2756202894/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

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Business Development Capture Director – Medicaid (Anthem)

Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care. This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America’s leading health care companies and a Fortune Top 50 Company.

Our Government Business Division’s Growth Team is looking for a Business Development Capture Director – Medicaid to join its Business Development and Capture Group. Our Business Development Capture Director is a high-performing individual contributor role responsible for positioning and capture execution of Medicaid health plan procurement and reprocurement opportunities. He/she is responsible for managing the strategy and preparations for upcoming Medicaid RFPs. He/she partners with Plan Presidents to lead the cross functional team of health plan leaders and business development to identify gaps, mitigate risks, and develop solutions and strategy in months prior to an RFP.

[This position can work remotely from any US Anthem location]

Primary duties may include, but are not limited to: Monitor and evaluate white space opportunities to make go/no-go recommendations to executive leadership. Develop and execute plans for the pursuit and capture of all Medicaid managed care procurement opportunities, including Alliance partnership opportunities. Leads the cross functional team of Growth Partners, Health Plan leaders, and Alliance partners (as applicable) to develop winning strategies and identify and mitigate risks and opportunities. Participates in bid decisions and develops recommendations for gate reviews. Collaborates with Health Plan Presidents and Health Plan leaders to understand current and emerging customer needs and requirements. Obtains market intelligence and competitive data to develop market strategy. Participates in all levels of proposal development and draft review, providing active feedback and recommendations for improvement. Provides mentorship and coaching to other members of the broader Business Development team.

Qualifications

Requires a BA/BS degree in a related field; 10 years of leadership/management experience in health care management, marketing products, and managing significant business results; or any combination of education and experience, which would provide an equivalent background.

Highly preferred experience:

-Previous P&L and/or business development experience and project management experience in Medicaid managed care setting.

-Experience leading capture and proposal activities for significant opportunities ($1B and more) strongly preferred.

-Experience in a capture function or executive leadership function for a managed care based product for state Medicaid agencies.

-State Medicaid agency experience or federal agency experience with CMS.

-MBA 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.

Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

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Contracting Officer Representative | Centers for Medicare & Medicaid Services

 
 

Summary This position is located in the Department of Health & Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Center for Medicare and Medicaid Innovation (CMMI), Business Services Group, Division of Central Contract Services. As a Contracting Officer Representative, GS-1101-9, you will perform assignments in support of local or centralized procurement activity, or in the audit/review of that activity. Responsibilities Interprets acquisition policy, guidance/provisions, news, including information and clarity on new and revised acquisition policies. Assists in conducting market research; developing acquisition strategies; prepares/develops contractual documentation. Develops and maintains an acquisition policy database within the Business Services Group Resource Center (SharePoint). Reviews and analyzes a variety of special and recurring reports and recommends corrective action on deficiencies. Develops and communicates written guidance on acquisition policy. Requirements Conditions of Employment Qualifications ALL QUALIFICATION REQUIREMENTS MUST BE MET BY THE CLOSING DATE OF THIS ANNOUNCEMENT. Your resume must include detailed information as it relates to the responsibilities and specialized experience for this position. Evidence of copying and pasting directly from the vacancy announcement without clearly documenting supplemental information to describe your experience will result in an ineligible rating. This will prevent you from receiving further consideration. In order to qualify for the GS-09, you must meet the following: You must demonstrate in your resume at least one year (52 weeks) of qualifying specialized experience equivalent to the GS-07 grade level in the Federal government, obtained in either the private or public sector, to include: 1) Assisting in the development of procurement packages to include statements of work, cost estimates, or schedules of deliverables. 2) Reviewing procurement or acquisition proposals for compliance with policies or regulations. 3) Interpreting acquisition policy and guidance related to contracts, grants, or cooperative agreements in order to advise stakeholders.


  • OR
  • Substitution of Education for Experience: You may substitute education for specialized experience at the GS-09 level by possessing a Master’s or equivalent graduate degree or 2 full years of progressively higher level graduate education leading to such a degree or LL.B. or JD, if related to the position being filled.
  • OR
  • Combination of Experience and Education: Only graduate education in excess of the amount required for the GS-07 grade level may be used to qualify applicants for positions at the grade GS-09. Therefore, only education in excess of 1 full year of graduate level education may be used to combine education and experience. TRANSCRIPTS are required to verify satisfactory completion of the educational requirement related to substitution of education for experience and combination of experience and education. Please see “Required Documents” section below for what documentation is required at the time of application. Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (eg, Peace Corps, AmeriCorps) and other organizations (eg, professional; philanthropic; religious; spiritual; community, student, social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience. Click the following link to view the occupational questionnaire: https://apply.usastaffing.gov/ViewQuestionnaire/11248297 Education Additional Information Bargaining Unit Position: Yes Tour of Duty: Flexible Recruitment/Relocation Incentive: Not Authorized Financial Disclosure: Not Required Telework Policy: CMS is on the forefront of offering flexible working arrangements, and after an initial training period, allows employees the opportunity to participate in telework combined with alternative work schedules at the supervisor’s discretion. In the current pandemic situation, employees are teleworking full time and supported by a variety of technologies. When CMS returns to normal operations, employees will be expected to return to the physical office duty station. CMS employees currently participating in 100% Full-Time Telework Program may be eligible to remain in the program. If an employee in this program is selected, the pay will be set in accordance with the locality pay for the applicable duty station. The listed salary range reflects the locality pay assigned to the duty location(s) listed in the vacancy announcement. For more information about pay based on locality, please visit the Office of Personnel Management (OPM) Salaries & Wages Page. The Interagency Career Transition Assistance Plan (ICTAP) and Career Transition Assistance Plan (CTAP) provide eligible displaced federal employees with selection priority over other candidates for competitive service vacancies. To be qualified you must submit the required documentation and be rated well-qualified for this vacancy. Click here for a detailed description of the required supporting documents. A well-qualified applicant is one whose knowledge, skills and abilities clearly exceed the minimum qualification requirements of the position. Additional information about ICTAP and CTAP eligibility is on OPM’s Career Transition Resources website at www.opm.gov/rif/employee_guides/career_transition.asp. Reasonable Accommodation Requests: If you believe you have a disability (ie, physical or mental), covered by the Rehabilitation Act of 1973 as amended and Americans with Disabilities Act 1990 as amended, that Reasonable Accommodation Requests: If you believe you have a disability (ie, physical or mental), covered by the Rehabilitation Act of 1973 as amended and Americans with Disabilities Act 1990 as amended, that would interfere with completing the USA Hire Competency Based Assessments, you will be granted the opportunity to request a reasonable accommodation in your online application. Requests for Reasonable Accommodations for the USA Hire Competency Based Assessments and appropriate supporting documentation for Reasonable Accommodation must be received prior to starting the USA Hire Competency Based Assessments. Decisions on requests for Reasonable Accommodations are made on a case-by-case basis. If you meet the minimum qualifications of the position, after notification of the adjudication of your request, you will receive an email invitation to complete the USA Hire Competency Based Assessments. You must complete all assessments within 48 hours of receiving the URL to access the USA Hire Competency Based Assessments, if you received the link after the close of the announcement. To determine if you need a Reasonable Accommodation, please review the Procedures for Requesting a Reasonable Accommodation for Online Assessments here: https://help.usastaffing.gov/Apply/index.php?title=Reasonable\_Accommodations\_for\_USA\_Hire.

 
 

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Quality Improvement Manager for Increasing Health Opportunities (Medicaid Health Systems Administrator 1) | Ohio Department of Medicaid

 
 

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


They Are


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.


  • 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 and
  • Increase program transparency and accountability.


Unless required by legislation or union contract, starting salary will be set at step 1 of the pay range.


Working Title: Quality Improvement Manager for Increasing Health Opportunities


Classification: Medicaid Health Systems Administrator 1 (PN 20091838)


Office: Health Innovation & Quality


Bureau: Health Research & Quality


Job Overview


As Quality Improvement Manager for Increasing Health Opportunities within the Ohio Department of Medicaid (ODM), you will be charged with synthesizing current research, policies, and programmatic information to develop and determine the effectiveness of interventions aimed at improving health opportunities at a population level. This will involve collaborating with other state agencies, other offices within the Ohio Department of Medicaid-ODM (Policy, Data Governance, Managed Care), ODM-contracted managed care entities, academic medical centers, community based organizations, and Medicaid providers to understand needs and priorities across the health system. A great deal of the work will involve synthesizing what is learned from your research and interactions within ODM and with other entities into succinct written and oral recommendations regarding potential programmatic, process, and policy improvements. This will involve working closely with other members of the ODM team. You will also be a part of the quality improvement project work aimed at reducing health disparities. This work includes developing and selecting measures to assess Ohio’s progress towards reductions in health disparities. You will use the insights gained from your interactions within ODM, as well as your research, and collaboration to draft and refine ODM’s Strategy for Increasing Health Opportunity. Successful applicants will think flexibly, easily adapt to new situations and contexts, have excellent written and oral communication skills, and engage in rigorous critical thinking and analysis of information for improvement.


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.


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


Primary Location


United States of America-OHIO-Franklin County-Columbus


Work Locations


Lazarus 5


Organization


Ohio Department of Medicaid


Classified Indicator


Classified


Bargaining Unit / Exempt


Exempt


Schedule


Full-time


Work Hours


8:00AM – 5:00PM


Compensation


$33.69/hour


Unposting Date


Nov 5, 2021, 10:59:00 PM


Job Function


Health Administration


Job Level


Individual Contributor


Agency Contact Information


HumanResources@medicaid.ohio.gov

 
 

 
 

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