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Senators seek Medicaid-like plan to cover holdout states

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US Congressmen are introducing a bill to sell Medicaid on the exchanges for free in holdout states.

 
 

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.

 
 

Sen. Raphael Warnock, D-Ga., speaks at Alfred E. Beach High School in Savannah, Ga., Thursday, July 8, 2021. Warnock joined fellow Democratic senators Jon Ossoff of Georgia and Tammy Baldwin of Wisconsin in introducing a bill on Monday, July 12, 2021, to require the federal government to set up a Medicaid-like health plan in states that have not expanded Medicaid plans to cover more low-income adults. (Jim Watson/Pool via AP)

Jim Watsdon

ATLANTA (AP) — Three Democratic U.S. senators from states that have refused to expand Medicaid want the federal government to set up a mirror plan to provide health insurance coverage to people in those states.

Sens. Raphael Warnock and Jon Ossoff of Georgia and Tammy Baldwin of Wisconsin are introducing the bill Monday, they told The Associated Press. Congressional Democrats are pushing for a coverage expansion in upcoming legislation.

“The single most effective solution to closing our state’s coverage gap is to expand Medicaid,” Warnock said after a June 29 meeting with health care executives. “What we ought to be doing is expanding Medicaid rather than playing games with the health care of Georgia citizens.”

The effort is crucial for Warnock, who seeks reelection in 2022 facing several Republicans eager to defeat him.

People making more than 138% of the federal poverty level are eligible for federal health insurance subsidies through an online marketplace. But as many as 4 million people who make less don’t get assistance in a “coverage gap,” according to the Kaiser Family Foundation.

President Barack Obama’s Affordable Care Act envisioned states would expand Medicaid programs to cover those people, but many conservative states balked. There are 12 holdouts, while an expansion in Missouri mandated by referendum is in limbo after Republican lawmakers refused to pay for it.

Democrats increasingly say leaving people without coverage is unacceptable. They tried to lure remaining states with two years of extra money for expansion, but none budged. Baldwin said such a refusal is “just wrong.”

“Our legislation will open the door to those who have been shut out and expand access to affordable health care, including preventive care, that people want and need,” she said in a statement.

The bill would mandate a new health insurance plan that looks just like Medicaid offered to residents in holdout states. President Joe Biden proposed during his campaign to offer a public option through the federal healthcare marketplace. Democratic Rep. Lloyd Doggett of Texas and others introduced a bill June 17 to let local governments create local Medicaid expansions.

The Medicaid approach has key advantages, said Jesse Cross-Call, director of state Medicaid strategy with the liberal-leaning Center for Budget and Policy Priorities.

The plan would require no premiums and only small copayments, while those costs can be much higher for individuals on the marketplace. People can enroll in Medicaid year-round, while marketplace enrollment is typically only in the fall, or when someone’s circumstances change.

“The idea is for it to be as close to Medicaid coverage as possible,” Cross-Call said.

A new plan could take years to set up, though. Many states use managed care networks to provide Medicaid services, and it’s unclear if the federal government would be able to contract with the groups.

Sponsors say coverage is already paid for because the original Affordable Care Act included money for all 50 states. States normally shoulder 10% of the cost, but the bill would require no state contributions.

The plan also would boost incentives for holdout states to expand on their own. It would raise the federal share of state-federal Medicaid spending by 10 percentage points this coming decade. The current enticement, included in Biden’s coronavirus relief bill, is 5 percentage points for two years. Based on Kaiser Family Foundation estimates, that could be worth a cumulative $160 billion to holdout states and Oklahoma, which launched expansion July 1.

Republicans, Warnock said in June, are effectively “standing between Georgia voters and their tax dollars that are still being paid to cover Medicaid in other states.”

Republicans aren’t backing down. Georgia Gov. Brian Kemp is pursuing a limited expansion that would impose work or education requirements for benefits. It seeks to add 50,000 Georgia residents in its first two years and require everyone to shop for federally subsidized insurance through private agents. The Biden administration is reevaluating previous approval of the plan by the Trump administration, a reversal Kemp says isn’t allowed.

“The Biden administration has been, in my opinion, trying to throw up roadblocks to our waiver plan that was approved,” Kemp recently told AP. “Senator Warnock can hit me all he wants on Medicaid. What he never mentions is … working on lowering costs for private sector health care. A lot of people don’t want government health care.”

Financial incentives could be required to keep other states from dropping Medicaid expansion to avoid current costs. The bill doesn’t address that.

Warnock spokesperson Meredith Brasher reaffirmed that sponsors want the measure attached to any budget reconciliation measure Democrats use to advance educational and social welfare priorities through the Senate without Republican support.

“Recovery legislation presents a unique, historic opportunity to close the gaps in coverage for the millions of people in the Medicaid coverage gap,” wrote more than 60 members of the Congressional Black, Hispanic and Asian Pacific American caucuses on June 16.

——Clipped from: https://www.pressrepublican.com/news/senators-seek-medicaid-like-plan-to-cover-holdout-states/article_0d7e832b-a349-59d1-a7d3-38a1fa65abdd.html

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Oregon Will Use Medicaid Funding For Mental Health Emergency Response

 
 

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Oregon is improve $10M to provide mental health crisis response.

 
 

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.

Oregon Legislature recently approved a bill that will help fund mobile mental health crisis teams around the state.
 

The bill allocates $10 million dollars of federal funding to be distributed across the state for crisis intervention centers.

Jackson County Representative Pam Marsh co-sponsored the bill. She says these crisis teams would complement police presence in terms of public safety during emergencies.

“What we’re trying to do is explore the idea that different kinds of professionals can be involved in responding to those 9-1-1 calls where there’s not a danger of violence or a need for someone to intervene in the way that law enforcement can intervene,” said Marsh.

Some of these professionals would be social workers, nurse practitioners, and mental health workers. They would address issues such as mental health crises and suicide threats.

Groups in Southern Oregon have been advocating for this bill in recent years. Marsh believes recent cases of people in mental health crises being killed during police encounters have led more Americans to rethink public safety methods.

“I certainly know that the Rogue Valley has been interested in this, and has been for a very long time,” she said. “We know that communities across the country woke up and started looking at these questions last summer. How many communities will actually come forward to put together a proposal? We’ll find that out in the grant process.”

Communities can apply for grant money to be used to assess existing resources, provide behavioral healthcare training, or develop and implement crisis intervention services. State Medicaid offices will be responsible for coordinating the mental health units.

 
 

Clipped from: https://www.ijpr.org/health-and-medicine/2021-07-19/oregon-will-use-medicaid-funding-for-mental-health-emergency-response

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Wisconsin Submits Plan to Enhance and Improve Medicaid Home and Community-Based Services

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Wisconsin is requesting additional federal money to improve HCBS services.

 
 

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.

 
 

Central to the plan are critical initiatives to strengthen the caregiving workforce left out of state budget passed by legislature

The Wisconsin Department of Health Services (DHS) has submitted a plan to the federal Centers for Medicare and Medicaid Services (CMS) to use American Rescue Plan Act (ARPA) funds to improve and enhance Wisconsin’s home and community-based services under Medicaid. DHS estimates it will receive approximately $350 million under this part of ARPA. Key components of the plan that support Wisconsin’s caregiving workforce include increasing rates for home and community-based services and expanding the professional advancement opportunities for the workers who provide these services.

“Strengthening our caregiver workforce and making investments in the services that many seniors and people with disabilities rely on across our state are critical steps we must take to support our economic recovery from the pandemic,” said Governor Tony Evers. “We are fortunate to have access to these federal funds to move these efforts forward since many of the proposals to support and strengthen our caregiving workforce included in my proposed state budget were removed by the legislature and not included in the budget that was recently passed.”

In consultation with key stakeholders and partners, DHS assembled a plan that will continue to advance Wisconsin’s successful record of implementing innovative programs that enable older adults and people with disabilities to live independently in their homes and communities. In Wisconsin, these efforts include the Family Care, Family Care Partnership, IRIS, PACE and the Children’s Long-Term Support programs, as well as personal care, private duty nursing, home health, and rehabilitative services provided to eligible Medicaid members.

“Wisconsin has long been a national leader in developing and implementing programs that allow the elderly and people with disabilities to live their best lives in their homes and communities. In 2021, we achieved a major milestone by fully eliminating the adult waiting list for home and community-based services,” said DHS Secretary-designee Karen Timberlake. “The ARPA funds designated by Congress and President Biden to support state home and community-based services will help us continue to build on that success and help stabilize and the services people depend upon as well as the workforce needed to provide them.”

Foundational to Wisconsin’s plan is a commitment to ensuring all eligible people in Wisconsin have access to home and community-based services by addressing health disparities and focusing on equity in program design and access. In addition to working with the Governor’s Health Equity Council to support implementation of the approved plan, DHS will work alongside community-based organizations that share our commitment to addressing disparities within the home and community based service system for Black, Indigenous, and people of color, people with varying abilities, people living in extremely rural areas, and other historically underserved and disadvantaged communities. Wisconsin is also engaging in individual conversations with each of the 11 federally recognized tribes to identify ways to enhance HCBS services for tribal members under the proposals in the submitted plan.

CMS is currently reviewing Wisconsin’s plan, along with those plans submitted by other states. Implementation efforts will begin once CMS approval is received.

Learn more by visiting the Proposed Funding for Home and Community-Based Services.

 
 

Clipped from: https://www.dhs.wisconsin.gov/news/releases/071421a.htm

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A Medicaid boost gives Colorado a chance to re-do disability services

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Colorado is requesting additional federal money to improve HCBS services.

 
 

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.

 
 

Funding for in-home personal care for aging Coloradans and people with disabilities would jump for three years under American Rescue Plan spending.

 
 

 
 

Nancy Bach, 63, and her niece Elizabeth, 36, on Monday, July 19, 2021, in Northglenn. Nancy struggles to fill Elizabeth’s pill boxes because her hands tremble, and aids have mistakenly caused Elizabeth to overdose by providing inaccurate amounts. Elizabeth, who has a developmental disability along with bipolar disorder, has lived with her aunt for five years and gone through four different home aid agencies. (Olivia Sun, The Colorado Sun)

Nancy Bach, 63, can handle most of the daily tasks for her 36-year-old niece, Elizabeth, who has developmental disabilities.

But Bach’s hands shake with persistent tremors, making it impossible to fill the pillboxes that sort her niece’s complicated array of prescriptions. The two of them need help, and good help is hard to find. 

When others have sorted the pills wrong, Elizabeth Bach has ended up in the hospital for a week for overdoses. Other weeks she has missed crucial Trazodone because an aid counted wrong. Recently the home health agency just stopped sending anyone to do it. 

Colorado is about to get $500 million over the next three years that advocates for people with disabilities hope will help solve problems experienced by the Bachs and many others. A bigger Medicaid match from the American Rescue Plan will help Colorado pay for things including better training for home health and personal care aids, retention bonuses, and new systems allowing caretaking families to directly hire their own choice of personal aid. 

That’s extremely welcome news to Bach and her niece.

“I know exactly who I’d hire, and there’d be no issue,” Bach said. 

The funds are a “once-in-career opportunity,” a chance to make systematic change in an industry that has long struggled to maintain workers, said Bonnie Silva, director of the state Office of Community Living at the Department of Health Care Policy and Financing, which includes the Medicaid program. 

 
 

Elizabeth Bach takes over a dozen medications and supplements at specific times of the day. Nancy, her aunt, struggles to fill her pill boxes because her hands tremble, and aids have mistakenly caused Elizabeth to overdose by providing inaccurate amounts. (Olivia Sun, The Colorado Sun)

The Medicaid department serves about 60,000 people through community-based programs, meaning programs for those who live at home and receive community services instead of living in institutions. The division spends about $2.5 billion on those services each year. Still, the extra $500 million is “an extraordinary amount of money” that will allow Colorado to transform its in-home programs, Silva said.

“It would be a shame if in 2024 we find ourselves with the exact same problems that we have today,” she said.

Letting people like Bach hire help of their choosing, and providing a larger pool of home aids trained in what clients actually need, is exactly how the new $500 million in Medicaid money could make a difference for thousands of Colorado families if done thoughtfully, said Julie Reiskin, executive director of the Colorado Cross Disability Coalition. 

“One of the problems I think we’ve always had in Colorado was that when we need to do something we were always in the situation where we have to do it cheap,” said Reiskin, who has for years been a leader of advocacy for more patient-directed home and community-based services through Medicaid. “And then we don’t do it right. So I think there’s a lot of systems change we could do that’s really exciting. And we have the time to do it properly.” 

 
 

Nancy Bach, 63, and her niece Elizabeth, 36, on Monday, July 19, 2021, in Northglenn. Elizabeth, who has a developmental disability along with bipolar disorder, has lived with her aunt for five years and has gone through four different home aid agencies. (Olivia Sun, The Colorado Sun)

To come up with a plan to spend the $500 million, the state Medicaid department held seven meetings attended by more than 800 people, plus gathered online surveys from about 450 others. The No. 1 issue was easy to identify: the workforce shortage in the in-home care industry. 

The challenge with the cash is that it’s a one-time allotment. Instead of just using the funds to increase the rate Medicaid pays to service providers, a boost that would end in three years, Colorado is trying to spend the money to come up with long-term fixes to a broken system. 

State officials want to create a training pool where people who work in the industry could get help earning certification to care for people with more complex health needs. They plan to spend money to hire a contractor who would come up with new policies for compensation and benefits that would make in-home care a “viable industry,” in which people could make a living and expect to advance, Silva said.

TODAY’S UNDERWRITER

Those new designs could include more avenues for clients like the Bachs to direct more of their care and payments, advocates noted. 

The spending plan, which still needs final approval from the federal Centers for Medicare and Medicaid, also includes money for respite care. Those funds would pay increased wages for workers willing to care for people while their relatives or regular caregivers get a break. 

Another part of the $500 million plan calls for hiring a contractor to study how best to transition large residential centers, such as nursing homes, into smaller settings. During the pandemic, smaller centers had more success keeping residents healthy, Silva said. 

Targeting the “invisible waitlist”

Colorado has struggled for decades to keep up with the need among those who, despite severe disabilities or aging, want to live in their own homes. 

The waitlist to get on a Medicaid program that provides round-the-clock, in-home services for adults with intellectual disabilities was about 15 years long seven years ago. State lawmakers have slowly invested in the program, and this year, the state plugged enough money into the program to enroll 667 on the waitlist, although there are still about 2,000 people waiting. 

But the waitlist is only part of the problem. Families say that even when they get a spot in the program, there is still an “invisible waitlist” to actually find service providers to come to their homes to cook, clean and care for loved ones. 

And while they are eligible for many of the services as they wait to get enrollment in the 24/7 program, it’s difficult to find workers who have openings in their schedule. 

At other times, regulations require clients and their caregivers to hire people with qualifications above what they truly need to be helpful in an at-home situation, Reiskin said. In the Bachs’ case, for example, what they need is someone reliable, who can read prescription information, and has some basic people skills. The state and the disability support community could use the Medicaid infusion to design new regulations and programs that make sense for thousands more clients, she said. 

Even before the coronavirus pandemic hit Colorado, the turnover rate among in-home service jobs was 82%, according to the Colorado Department of Health Care Policy and Financing. State officials suspect it’s only gotten worse in the last year. 

 
 

A pillow made by Elizabeth Bach (not pictured) is framed on the wall of the Bachs’ home in Northglenn. Elizabeth’s favorite hobbies are swimming, crafting and collecting keychains. (Olivia Sun, The Colorado Sun)

Among workers who care specifically for people with intellectual disabilities, the turnover rate pre-pandemic was 40%, said Ellen Jensby, senior director of public policy and operations for Alliance Colorado, which advocates for people with disabilities. As Coloradans isolated themselves during the pandemic, many workers left the in-home care industry, she said.

“What we’ve heard from the providers is that they are having a harder time than ever right now trying to recruit people to come back into the workforce,” Jensby said. “They are trying everything to get people through the door, including recruitment bonuses. Everybody has a ‘We’re Hiring’ sign on their door.” 

But unlike coffee shops and fast food restaurants, which can raise their prices in order to pay staff higher wages, the system for people with disabilities is dependent on reimbursement rates set by the government.

Providers who run day programs, such as adult daytime care or field trips to museums, are extremely low on staff, Jensby said, as are transportation providers and programs that provide job training and on-the-job support for people with disabilities. 

“The result is they are not able to reopen many of their services fully,” Jensby said. “They just don’t have enough staff to bring everyone back. Families are like, ‘We’re ready! We’re vaccinated!'”

TODAY’S UNDERWRITER

Still, there were stories of dedication from these other “first-responders,” the folks who donned masks and continued going to work each day alongside nurses, grocery store workers and others whose jobs couldn’t stop because of coronavirus.

“We saw the dedication really shine,” Jensby said. “There were people who quarantined for days or a week with families, … stayed with people they cared for instead of going home to their families. Just amazing stuff.”

Rate increases, along with reform

Alliance is thrilled that Colorado plans to use the extra $500 million to boost pay, recruitment and training for in-home care workers, but those workers need help in the short term, too, Jensby said. The advocacy organization also is pushing for rate increases now so that agencies can afford to pay the salaries and signing bonuses needed to hire workers. 

In legislative and congressional hearings, people talk about how the workforce shortage in the in-home service industry has reached the level of a “crisis.” But Jensby said it’s been a crisis for decades — at this point, “it’s a systematic failure.”

The state legislature passed a bill, Senate Bill 286, that gives the health care department broad authority to spend the bolstered Medicaid matching funds once the state gets the go-ahead from federal officials. If all goes as planned, Colorado should get to start spending the $500 million by early September.

 
 

The Colorado Sun has no paywall, meaning readers do not have to pay to access stories. We believe vital information needs to be seen by the people impacted, whether it’s a public health crisis, investigative reporting or keeping lawmakers accountable.

This reporting depends on support from readers like you. For just $5/month, you can invest in an informed community.

Clipped from: https://coloradosun.com/2021/07/20/disabilities-medicaid-funding/

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Senior Provider Contracting Professional – Ohio Medicaid job in Cincinnati, OH | Humana Inc.

 
 

 
 

Description

The Senior Provider Contracting Professional initiates, negotiates, and executes physician, hospital, and/or other provider contracts and agreements. The Senior Provider Contracting Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities

The Senior Provider Contracting Professional negotiates contract terms, payment structures, and reimbursement rates to providers. Analyzes financial impact of contracts and terms. Maintains contracts and documentation within a tracking system. Identifies and recruits providers based on network composition and needs. Helps to influence department’s strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.

Required Qualifications

  • Bachelor’s degree
  • 3 or more years of progressive network management experience including hospital contracting and network administration in a healthcare company
  • Experienced in negotiating managed care contracts with large physician groups, ancillary providers and hospital systems.
  • 1-2 years of experience working with Ohio Medicaid with understanding of Ohio Medicaid compliance
  • Proficiency in analyzing, understanding and communicating financial impact of contract terms, payment structures and reimbursement rates to providers.
  • Excellent written and verbal communication skills
  • Ability to manage multiple priorities in a fast-paced environment
  • Proficiency in MS Office applications
  • Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

  • Master’s Degree
  • Experience with ACO/Risk Contracting
  • Experience with Value Based Contracting

Additional Information

This position is considered “remote/work at home”, however, you must live within the State of Ohio to be considered for this opportunity.

Scheduled Weekly Hours

40

 
 

Clipped from: https://getwork.com/details/0e8f5fbdb907d44195e1e148ac67008a?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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CareFirst BlueCross BlueShield Supervisor, Utilization Management (MD Medicaid) Job in Owings Mills, MD

 
 

Resp & Qualifications

PURPOSE:

Supervise the daily operations of the utilization management (UM) department functions to ensure appropriate coordination of health care services and compliance with UR policies/procedures, as well as, regulatory and CareFirst’s accreditation standards.

PRINCIPAL ACCOUNTABILITIES:

This position reports to the Utilization Review Manager. Primary accountabilities include, but are not limited to, the following:

Manages the delegation of assignments and supervises UR associates. Routinely assesses and evaluates UR associate workloads/functions for compliance to process and standards, appropriateness in quality of work and productivity. Assists/directs handling of complex cases to ensure appropriateness for documentation and inclusion of other internal departments, including but not limited to Physician Reviewers, Central Appeals, etc. Collaborates and acts as a resource to UR staff and other internal customers regarding UR process, including, but not limited to, benefit contracts, coordination of care, adverse decisions, problem solving, or development of interdepartmental workflows. Performs Utilization Review when coverage warrants.


Provides mentoring and guidance to develop, expand and improve associates’ skills and expertise. Conducts individual and regular staff meetings to maintain ongoing communication. Conducts inter-rater reviews, providing feedback on a quarterly basis or more often as indicated by performance. Ensures that UR associates have the information and resources needed to accomplish their assignments. Works with UR Supervisors and/or trainer to coordinate the orientation program for new associates, including evaluation of new associate performance as per UR policy/procedures.


Actively participates in the development, design, and implementation of utilization review processes and procedures or new CareFirst programs as assigned by Manager. Maintains UR policies and procedures to ensure UR process and goals are supported; this includes an annual review of policies and procedures. Maintains current knowledge of regulatory and/or accreditation standards. Ensures that the required elements for the standards are current and incorporated in the UR process. Performs projects or other tasks as delegated. Uses/analyzes UR data to provide insight regarding trends, staffing, case load ratio, etc., that could impact the UR process. Performs projects or other tasks as delegated.

Communicates in a timely manner to Manager appropriate information including, but not limited to, customer/case issues, reports, trends/variances, action plans, etc. Meets routinely with peers, staff and/or Manager to communicate/update as pertinent. Acts as a liaison with external customers to ensure coordination of care and services as appropriate for effective management of benefits and quality of care. Plans and implements meetings with provider community to proactively facilitate change, improve service and coordinate UR activities.


QUALIFICATION REQUIREMENTS:



Required:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The
requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable
accommodations may be made to enable individuals with disabilities to perform the essential functions.

This position requires an active RN license in the CareFirst region with five years of medical/surgical experience including, but not limited to, inpatient care, outpatient/home care and hospice care, three years experience reviewing patient medical care and one year in a supervisory role or equivalent work experience in team leadership, training or project management.

Preferred Qualifications:

Bachelor’s degree in Nursing with one to two years of experience in managed care. Thorough knowledge of CareFirst clinical guidelines, medical policies and accreditation and regulatory standards relating to utilization review. Experience in claims review and in using, diagnosis and procedure codes.

Knowledge, Skills and Abilities (KSAs

Knowledge of accreditation standards and federal/state regulations and general principles relating to
utilization review. Advanced
Computer skills, including Microsoft Office programs. Proficient
Ability to mentor and coach associates to accomplish goals, provide objective evaluation of associate
performance, and implement strategies to improve individual and team-based performance as needed. Proficient
Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for
flexibility Expert
Excellent analytical, problem-solving skills with ability to judge appropriateness of member services and
treatments on a case by case basis Expert
Effective written and interpersonal communication skills to engage with members, healthcare
professionals, and internal colleagues Advanced

Additional Skills and Abilities
The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her
ineligible to perform work directly or indirectly on Federal health care programs. Must be able to effectively work in a
fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long
periods of time. Must be able to meet established deadlines and handle multiple customer service demands from
internal and external customers, within set expectations for service excellence. Must be able to effectively
communicate and provide positive customer service to every internal and external customer, including customers
who may be demanding or otherwise challenging.

Licenses and Certifications
RN – Registered Nurse – Maryland, Washington, DC or Compact State

Department

Department: MD Medicaid -HEALTH SERVICES

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Closing Date

Please apply before: 8/19/21

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

 
 

Clipped from: https://www.glassdoor.com/job-listing/supervisor-utilization-management-md-medicaid-carefirst-bluecross-blueshield-JV_IC1153614_KO0,45_KE46,76.htm?jl=1007187674680&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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Director Medicaid Programs | Chicago, IL | HCSC

 
 

JOB PURPOSE:
This position is responsible for directing the activities related to the business operations of the Medicaid Managed Care operations in accordance with contractual and regulatory requirements. Directs the development of infrastructure, standards and policies and procedures of program changes and works with other areas of the organization on the development, testing and implementation of organization, process and system changes to ensure the requirements of the Medicaid program are met, specifically around claims processing and management, . Organizes, manages, and facilitates, bi-monthly Medicaid Oversight and Operations inter-departmental Team. Also serves as the liaison with vendors and internal functional areas and assists in the coordination of the contract with Medicaid Division for the State and also represents BCBS at key State meetings. This position must ensure that operations run effectively and efficiently, while meeting all contract requirements and performance standards. Provides direction and training to staff. Adherence to compliance and audit requirements is essential. Serves as primary contact for external audits on Medicaid Business; directs the internal activities during such reviews and audits

JOB REQUIREMENTS:
* Bachelor Degree in Business with 6 years experience OR 10 years experience working in health insurance operations.
* 5 years management experience.
* Demonstrated experience in project management.
* Medicaid operational experience.
* Knowledge of contract and rate reimbursement provisions relating to hospital, home health agencies, nursing facilities, and other Medicaid providers.
* Demonstrated ability to work directly with corporate leadership.
* Leadership, organization, self-motivation and initiative skills.
* Demonstrated ability to manage multiple complex priorities.
* PC proficiency to include Word, Excel, and Lotus Notes.
* Analytical skills and presentation skills.
* Verbal and written communication skills.
* Presentation skills to speak to large audiences and meeting facilitation skills for external agency meetings.

PREFERRED JOB REQUIREMENTS:

* Experience with government contracts.
* Management experience in a health care or managed care environment
* Experience in the health care industry.

Clipped from: https://www.themuse.com/jobs/hcsc/director-medicaid-programs-4c024f?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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Manager, Medical Claims Review

 
 

Our Mission:  Provide the best value in health insurance and related health services to improve the quality of life for Arizonans.

Our Vision: 

Inspire health in Arizona as the trusted leader in delivering affordable, innovative healthcare solutions.

Our Benefits: Our benefits provide work-life balance and the flexibility you need to be your best. We offer comprehensive medical, dental, and vision coverage; a 401K savings plan; paid holidays and vacations; and much more!

Position Purpose:

The Manager, Medical Claims Review department is responsible for leading a team of nurses and paraprofessionals in reviewing and analyzing medical claims to ensure medical necessity for services rendered, right level of care, correct billing and coding procedures are substantiated for inpatient and outpatient claims. This position requires consistent application of InterQual Criteria and Medicaid and Medicare billing and coding expertise.

Responsibilities:

  • Develops procedures and processes for team adherence to claim review and documentation based on best practice
  • Write job aids, policies, train staff, and ensure all regulatory standards are met for Medicaid, Medicare, and NCQA
  • Evaluate data and provide direction, course correction, and leads process improvement
  • Coach and mentor staff; work with senior leaders on employee performance issues
  • Directs professionals and paraprofessionals to deliver on all KPIs for the health plan
  • Tracks data, analyzes findings for medical claims decisions, disputes, and provider response
  • Meets with providers in JOCs and as needed
  • Responsible for the day to day operations of the department
  • Conducts claim reviews and provides accurate and detailed abstracts for Medical Director review
  • Maintains and updates authorizations in medical management system and the claims system
  • Collaborates with Network Services leadership to educate providers on correct coding, billing, and clinical documentation

Education / Experience / Other Requirements

Education:

  • RN; BSN preferred
  • Arizona unrestricted RN license required
  • Certified coder

Years of Experience:

  • 2-3 years direct clinical experience
  • 1-2 years managed care/health plan experience preferred
  • 1-2 years medical claims review experience
  • Medicaid and Medicare experience preferred
  • Prior management experience 2 or more years

Specialized Knowledge:

  • Claims review tenets
  • Computer skills including MS Word, Excel spreadsheets
  • Communication skills: oral and written

Skills & Abilities:

  • Ability to manage multiple projects and prioritize adhere to deadlines/time frames
  • Ability to supervise and lead others
  • Ability to manage regulatory deliverables

*Position Located in Arizona*

 
 

Clipped from: https://www.healthchoicejobs.com/manager-medical-claims-review/job/15095386?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Posted on

Medicaid Enterprise Architect

 
 

About the job

Medicaid Enterprise Architect

Knowledge of the MITA Business, Information and Technical architectures.

Knowledge of the Medicaid Systems and Solutions.

Experience with data integration and mapping.

Claims and Financial Processing.

Familiarity with HIPAA rules and regulations.

Job Details

Seniority Level

Mid-Senior level

Industry

  • Information Technology & Services

Employment Type

Contract

Job Functions

  • Design
  • Art/Creative
  • Information Technology

Pay range unavailable

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Established in 2000, LanceSoft is a Certified MBE and Woman-Owned organization, and a pioneer in providing premium end-to-end Global Workforce Solutions and IT Services to diverse clients across various domains.

LanceSoft’s mission is to establish global cross-culture human connections that further the careers of our employees and strengthen the businesses of our clients. We are driven to use the power of our global network to connect businesses with the right people, and people with the right businesses without bias. We provide Global Workforce Solutions with a human touch.


We offer a gamut of services across diverse domains, categories, skill sets with varying lengths of assignments including:

– Temporary Staffing
– Permanent Staffing
– SOW
– Payrolling
– Recruitment Process Outsourcing (RPO)
– Application Design and Development
– Program/Project Management
– Engineering Solutions

With currently over 3,800+ staff serving over 110+ enterprise clients worldwide including “Fortune” companies, LanceSoft serves a wide array of industries including Banking & Financial Services, Semiconductor/VLSI, Technology, Healthcare & Life Sciences, Government, Telecom & Media, Retail & Distribution, Oil & Gas and Energy & Utilities.


LanceSoft is headquartered in Herndon, VA with 27 regional offices across the U.S. and 21 offices around the globe. We have five delivery centers in India – Bangalore, Indore, Noida, Baroda and Hyderabad to further serve our clients.


Our awards and accolades in the US Contingent Workforce space:

Accredited by the Better Business Bureau (BBB).
Best of Staffing Client Satisfaction 2021, 2020, 2019
Best of Staffing Talent Satisfaction 2021, 2020
2020 Workforce Logiq Proven Performer (third consecutive year)
2020 SIA Largest Staffing Firms in the US
2020 SIA List of Diversity Staffing Firms
2020 SIA Fastest Growing US Staffing Firms (third consecutive year)
2020 SIA Largest Life Sciences Staffing Firms in the US …

 
 

Clipped from: https://www.linkedin.com/jobs/view/medicaid-enterprise-architect-at-lancesoft-inc-2648210972/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic