• Everywhere you turn, you can feel it.  There’s an immeasurable level of enthusiasm at East Boston Neighborhood Health Center (EBNHC), one of the largest community health centers in the country.  From the nurses and physicians on the front line of patient care, to the managers who shape our policies, to the customer service representatives who keep our facilities running smoothly – everyone here has a role in making medicine better.
  Interested in this position?  Apply on-line and create a personal candidate account!
  Current Employees of EBNHC – Please use the internal careers portal to apply for positions.
  To learn more about working at EBNHC and our benefits, check out our Careers Page at careers.ebnhc.org.
  Time Type:
  Full time
  Department:
  Quality
  All Locations:
  East Boston
  Description:
  EBNHC is a member of Community Care Cooperative (C3), an organization formed by 13 Federally Qualified FQHCs located throughout the Commonwealth of Massachusetts. C3, a 501(c)(3) non- profit Accountable Care Organization (ACO), is taking responsibility for managing the cost and quality of health care for MassHealth enrollees. C3’s vision is transforming the health of underserved communities. As a member of C3, EBNHC is uniquely positioned to be a true innovator in meeting quality goals and reducing cost of care for a large Medicaid population.
  The Population Health Manager (PHM) will be responsible for driving value based care initiatives at EBNHC. Partnering closely with EBNHC leadership, providers, and staff, you will integrate C3’s clinical programs and resources into the practice workflows with the intent to optimize the enrollee experience, and positively impact provider engagement and quality of care provided.
  Education
  
• Bachelor’s Degree
  Experience
  
• 5+ years of leadership experience in practice management, provider relations and project management
  

<https://ebnhc.wd1.myworkdayjobs.com/EBNHC/job/East-Boston/Quality-Improvement-and-Population-Health-Manager_R0002612?source=Indeed>

Description

Job Summary: Oversees network and analytics strategy and execution for Delta Dental’s government business, including delivery of Medicaid and Medicare population health strategies. Directs matrix-oriented delivery model that ensures enterprise is delivering government-specific solutions unique to federal and state regulations.

Primary Job Responsibilities

1. Directs the daily activities of the team responsible for government programs network management, clinical performance, social determinants of health (SDOH), and the application of data analytics in maintaining optimal results.

2. Develops, recommends, and implements short and long term action plans in order to ensure the achievement of business unit goals.

3. Serves as leader in the development and monitoring of Medicare and Medicaid networks.

4. Establishes analytics function within the government programs business unit that is integrated into decision-making.

5. Communicates with and advises executive management on the planning and activities of government business.

6. Create and maintains governance of operational issues pertaining to government programs.

7. Supports business development efforts and serves as primary point of contact for network issues with clients.

8. Interviews, hires, evaluates, manages, and develops staff in order to ensure accountability for the achievement of departmental and individual goals and objectives.

Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.

Location

Delta Dental MI-Farm Hills-DDFH

Requirements

Position requires a bachelor’s degree with an emphasis in business administration or a related field, seven years of experience in Medicaid, Medicare, insurance and / or clinical operations, and three years of leadership experience.

Position requires experience in provider contract network development, management, optimization and familiarity of various provider compensation models including fee-for-service, capitation, value-based reimbursement, risk sharing, etc.

Position also requires advanced knowledge of the managed care industry, strong verbal and written communication skills; strong interpersonal skills; and the ability to resolve complex problems using independent judgment.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

Clipped from: https://recruiting.adp.com/srccar/public/RTI.home?c=1214201&d=TRI&rb=INDEED&r=5000670111306#/

Molina Healthcare Job ID 2006424

Apply Now

Job Description
Job Summary
This role will have a heavy focus on leading our reporting and analytics in A&G. Responsibilities include leading an audit and analytics team, managing/improving quality reporting, analyzing trends and ad hoc reporting. Ideal candidates would have experience in Appeals & Grievances, Medicaid reporting and analytics and reporting.

Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member complaints and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid.

Knowledge/Skills/Abilities

• Reviews and analyzes collective grievance and appeals data along with audit results on unit’s performance; analyzes and interprets trends and prepares reports that identify root causes of member/provider dissatisfaction
• Recommends and implements process improvements to achieve member/provider satisfaction of operational effectiveness/efficiencies.
• Leads, organizes, and directs the activities of the Appeals & Grievance unit that is responsible for member and provider Appeals and Grievances for Marketplace. 
• Provides direct oversight, monitoring and training of provider dispute and appeals units to ensure adherence with Marketplace standards and requirements.
• Trains grievance and appeals staff and other departments within Molina Marketplace on early recognition an timely routing of member complaints
• Trains provider dispute resolution unit on Marketplace standards and requirements, including the proper use of the Molina Appeals and Grievance system.

Job Qualifications

• Strong claims background
• Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing).
• Management of 100+ employee’s experience.
• 7 years’ experience in healthcare claims review and/or member appeals and grievance processing/resolution, including 2 years in a manager role.
• Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB92, 2 years supervisory/management experience with appeals/grievance processing within a managed care setting.

Required Education
Associate’s Degree or 4 years of grievance and appeals experience.

Required License, Certification, Association

None

Preferred Education
Bachelor’s Degree

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

About Us

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Job Type: Full Time Posting Date: 01/11/2021

Clipped from: https://careers.molinahealthcare.com/job/-/-/21726/18446736?src=Indeed

The Senior Enrollment Medicaid Specialist will be the first source of job-related information and will support and assist with tasks/training relating to Integrated Products (IP), Management Services Organizations (MSO), Marketing Specialists and the PHSP lines of business within enrollment and retention. This includes, but is not limited to train/teach product, process and policy information at the onset of the hiring process as well as on a continuous basis. Being proficient in their ability to communicate with impact, apply critical thinking and possess leadership skills. The Senior Enrollment Medicaid Specialist will act as a role model and provide continuous coaching and feedback to the team. They will also assist and work closely with the Quality Performance Team in monitoring the quality of application submitted, track enrollment performance behaviors, identify areas for improvement and recommend to the proper Management Team. Senior Enrollment Medicaid Specialist will develop talent by identifying the Specialist strengths and suggest them for project work.

• Interprets product, procedural and regulatory information, and assists with the development of training curricula to provide field staff with available services
• Administer new hire training and refresher training to the Marketing Specialists, Relationship Coordinators, and Enrollment Medicaid Specialist teams
• Participates in the development, implementation, and updates provided by Healthfirst to ensure departmental compliance
• Due to the nature of additional responsibility, their home visits will be substantially lower than any of the other Enrollment Medicaid Specialists but will be required to make visits when needed
• Provide expertise and customer service support to the teams and consumers.
• Conduct observational field visits and provide guidance and support to the teams
• Aids in increasing individual and team effectiveness by creating and distributing training resources, learning aids and process documentation to learners
• Prepares and maintains reports/records on training program attendance and programs offered
• Participates in any training-related projects as scheduled or otherwise directed by the Director of Training and is expected to provide viable input for all projects and ensure that all assignments are completed with quality and accuracy
• Serve as the subject matter expert in all services offered
• Liaison between Local Department of Social Services, New York Medicaid Choice, and internal department
• Assist in the scheduling of staff for training
• Must have excellent listening, as well as written and oral communication skills
• Must have strong interpersonal skills and professional attitude

Minimum Qualifications:

• Associate’s Degree
• Proficiency in navigating the Internet and multitasking with multiple software/electronic documentation systems simultaneously
• Excellent written communication and the ability to document grammatically correct notes and correspondence
• Ability to be independent in making sound decisions and proactive in identifying and implementing process improvements
• Aptitude for using a fast-paced proactive vs. reactive approach, maneuvering multiple tasks simultaneously including seamlessly changing priorities
• Establish credibility and trust along with positive and affable working relationships with internal and external clients

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement

All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst.  Healthfirst will never ask you for money during the recruitment or onboarding process.

Clipped from: https://careers.healthfirst.org/us/en/job/R009061/Sr-Enroll-Medicaid-Spec?mode=job&iis=Job+Board&iisn=Indeed.com

Medical Director – Medicaid (Remote)

Job Locations

Remote

Job ID

2020-10798

Category

Product Development

Overview

As the Medicaid Medical Director, Medicaid you will to be a part of our innovative product solution development team. You will assist in crafting products tailored for individuals covered by Medicaid to afford them the opportunity to successfully live, heal and age at home. You will be an integral part of internal and external client meetings, sales opportunities, product implementation and quality processes. 

Responsibilities

• Serve as the Medicaid clinical lead for all quality, clinical, utilization management, and policies for Medicaid and LTSS programs.
• Provide leadership and coordination for the development and implementation of a cohesive approach to measuring and promoting quality, and lead priority-setting process for clinical quality improvement for Medicaid and LTSS programs.
• Provide clinical support and expertise focusing on Medicaid and LTSS for program development.
• Participate in leadership, stakeholder and Advisory Board meetings
• Build and maintain effective working relationships with cross-functional leaders and teams in order to identify, explore, present and implement Medicaid program opportunities.

Qualifications

• MD or DO with an active and unencumbered medical license.
• 5 years’ plus  experience in an area of relevant clinical practice
• 5 years’ plus experience with a Medicaid health plan, or a State Medicaid Agency. LTSS population experience preferred.
• Excellent verbal and written communication skills and be able to communicate effectively in large and small group settings.
• Medicaid thought leader with market intelligence.
• Experience with Medicaid and LTSS program utilization management, clinical management, program development, or program evaluation—either with a health plan, Medicaid Managed Care organization or state Medicaid Agency
• Ability to develop, collaborate with, and support relationships with key stakeholders internally and externally (client CMOs and Medicaid Associations)

Clipped from: https://careers-carecentrix.icims.com/jobs/10798/job?utm_source=indeed_integration&iis=Job+Board&iisn=Indeed&indeed-apply-token=73a2d2b2a8d6d5c0a62696875eaebd669103652d3f0c2cd5445d3e66b1592b0f&mode=job&iis=Indeed&iisn=Indeed.com&mobile=false&width=1479&height=500&bga=true&needsRedirect=false&jan1offset=-360&jun1offset=-300

Supplemental Information

Job Number: MVA/SAG/1961
 
 This position is located within the Louisiana Department of Health l Medical Vendor Administration l Program Integrity  l  EBR Parish.
 
 Cost Center: 0305-7104
 Position Number(s): 50550788
 
This vacancy is being announced as a Classified position and may be filled either as a Probationary Appointment, Job Appointment or Promotional Appointment.  

(Job Appointments are Temporary Appointments up to 48 months)

 
****REVIEW YOUR APPLICATION TO MAKE SURE IT IS CURRENT. Failure to provide your qualifying work experience may result in your application not being considered.****
 
 
There is no guarantee that everyone who applies to this posting will be interview.  The hiring supervisor/manager has 90 days from the closing date of the announcement to make a hiring decision.  Specific information about this job will be provided to you in the interview process, should you be selected.

No Civil Service test score is required in order to be considered for this vacancy.  
 
To apply for this vacancy, click on the “Apply” link above and complete an electronic application, which can be used for this vacancy as well as future job opportunities. Applicants are responsible for checking the status of their application to determine where they are in the recruitment process. Further status message information is located under the Information section of the Current Job Opportunities page.
 
*Resumes WILL NOT be accepted in lieu of completed education and experience sections on your application. Applications may be rejected if incomplete.*
 
For further information about this vacancy contact:
Sanaretha Gray @ Sanaretha.Gray@la.gov    
LDH/HUMAN RESOURCES
P.O. BOX 4818 BATON ROUGE, LA 70821
225 342-6477
 

 

Qualifications

MINIMUM QUALIFICATIONS:

A baccalaureate degree plus four years of professional experience in administrative services, economics, public health, public relations, statistical analysis, social services, or health services.

SUBSTITUTIONS:
Six years of full-time work experience in any field may be substituted for the required baccalaureate degree.

Candidates without a baccalaureate degree may combine work experience and college credit to substitute for the baccalaureate degree as follows:

A maximum of 120 semester hours may be combined with experience to substitute for the baccalaureate degree.

30 to 59 semester hours credit will substitute for one year of experience towards the baccalaureate degree.
60 to 89 semester hours credit will substitute for two years of experience towards the baccalaureate degree.
90 to 119 semester hours credit will substitute for three years of experience towards the baccalaureate degree.
120 or more semester hours credit will substitute for four years of experience towards the baccalaureate degree.

College credit earned without obtaining a baccalaureate degree may be substituted for a maximum of four years full-time work experience towards the baccalaureate degree. Candidates with 120 or more semester hours of credit, but without a degree, must also have at least two years of full-time work experience tosubstitute for the baccalaureate degree.

Graduate training with eighteen semester hours in one or any combination of the following fields will substitute for a maximum of one year of the required experience on the basis of thirty semester hours for one year of experience: public health; public relations; counseling; social work; psychology; rehabilitation services; economics; statistics; experimental/applied statistics; business, public, or health administration.

A master’s degree in the above fields will substitute for one year of the required experience.

A Juris Doctorate will substitute for one year of the required experience.

Graduate training with less than a Ph.D. will substitute for a maximum of one year of the required experience.

A Ph.D. in the above fields will substitute for two years of the required experience.

Advanced degrees will substitute for a maximum of two years of the required experience.

NOTE:
Any college hours or degree must be from a school accredited by one of the following regional accrediting bodies: the Middle States Commission on Higher Education; the New England Association of Schools and Colleges; the Higher Learning Commission; the Northwest Commission on Colleges and Universities; the Southern Association of Colleges and Schools; and the Western Association of Schools and Colleges.

Job Concepts

Function of Work:
To administer small and less complex statewide Medicaid program(s).

Level of Work:
Program Manager.

Supervision Received:
Broad from a higher-level manager/administrator.

Supervision Exercised:
May provide functional supervision in accordance with the Civil Service Allocation Criteria Memo.

Location of Work:
Department of Health and Hospitals.

Job Distinctions:
Differs from Medicaid Program Monitor by responsibility for administering small and less complex statewide program(s).

Differs from Medicaid Program Manager 1-B by the absence of supervisory responsibility.

Differs from Medicaid Program Manager 2 by the absence of responsibility for administering medium size and moderately complex statewide program(s).

Examples of Work

Supervises the auditing of eligibility enrollment of all Medicaid programs statewide.

Reviews work of eligibility review staff for quality assurance.

Plans, coordinates, and controls small or less complex statewide program(s).

Plans, develops, implements and monitors comprehensive Medicaid program policies.

Conducts and directs studies/special projects pertaining to the programs assigned.

Analyzes the impact of federal, state, and local legislation; advises agency officials; prepares position statements; presents testimony at hearings; writes legislation.

Reviews and analyzes complex data and system reports to ensure compliance with program regulations.

Administers the day-to-day operational functions of the Medicaid fee for service programs. Assures that program policy and procedures are properly applies in accordance with federal and state laws and regulations.

Develops and writes agency rules and regulations governing the administration of all supervised Medicaid programs and submit them for publishing in the official state publication in accordance with the requirements of the Administrative Procedures Act.

Implements Medicaid regulations directing provider participation standards and recipient benefits. Analyzes multi-mullion dollar Medicaid claim data and project the fiscal impact for budget forecasting.

Identifies, verifies and analyzes the various revenue sources for the program(s). Determines and/or confirms match requirements. Monitors availability of revenue sources and promptly identifies existing or potential financing problems.

Benefits

Louisiana State Government represents a wide variety of career options and offers an outstanding opportunity to “make a difference” through public service. With an array of career opportunities in every major metropolitan center and in many rural areas, state employment provides an outstanding option to begin or continue your career. As a state employee, you will earn competitive pay, choose from a variety of benefits and have access to a great professional development program.

Flexible Working Arrangements – The flexibility of our system allows agencies to implement flexible working arrangements through the use of alternative work schedules, telecommuting and other flexibilities. These arrangements vary between hiring agencies.

Professional Development – The Comprehensive Public Training Program (CPTP) is the state-funded training program for state employees. Through CPTP, agencies are offered management development and supervisory training, and general application classes on topics as diverse as writing skills and computer software usage.

Insurance Coverage – Employees can choose one of several health insurance programs ranging from an HMO to the State’s own Group Benefits Insurance program. The State of Louisiana pays a portion of the cost for group health and life insurance. Dental and vision coverage are also available. More information can be found at www.groupbenefits.org.

Deferred Compensation – As a supplemental retirement savings plan for employees, the State offers a Deferred Compensation Plan for tax deferred savings.

Holidays and Leave – State employees receive the following paid holidays each year: New Year’s Day, Martin Luther King, Jr. Day, Mardi Gras, Good Friday, Memorial Day, Independence Day, Labor Day, Veteran’s Day, Thanksgiving Day and Christmas Day. Additional holidays may be proclaimed by the Governor. State employees earn sick and annual leave which can be accumulated and saved for future use. Your accrual rate increases as your years of service increase.

Retirement – State of Louisiana employees are eligible to participate in various retirement systems (based on the type of appointment and agency for which an employee works).  These retirement systems provide retirement allowances and other benefits for state officers and employees and their beneficiaries. State retirement systems may include (but are not limited to): Louisiana State Employees Retirement System (www.lasersonline.org), Teacher’s Retirement System of Louisiana (www.trsl.org), Louisiana School Employees’ Retirement System (www.lsers.net), among others. LASERS has provided this video to give you more detailed information about their system.

Clipped from: https://www.governmentjobs.com/careers/louisiana/jobs/2949308/medicaid-program-manager-1-a

Description

SHIFT: Day Job

SCHEDULE: Full-time

 

Your Talent. Our Vision. At Healthy Blue, a strategic alliance of Blue Cross NC and Amerigroup, an Anthem Inc. company, 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 benefits companies and a Fortune Top 50 Company

This position may be remote within NC and will be responsible for overseeing a designated region of NC. Home office location: 11000 Weston Parkway, Cary, NC. Candidates must reside in the state of NC or neighboring states. Currently, this position is remote due to COVID. Once we resume all standard operations, travel time for this position will be as indicated under the Requirements section. 

The Provider Clinical Liaison supports primary care groups in Advanced Medical Home population health activities. This position serves a key role in Healthy Blue’s geographically organized provider support. The Clinical Liaison is responsible for managing quality and medical expense goal metrics for primary care groups by assisting in connecting high risk members and those having HEDIS gaps to their medical homes, to establish care plans that improve health outcomes. 

Primary duties include:

• Use Healthy Blue databases and tools, including risk adjustment tools to identify opportunities for improvement in quality and costs for members in assigned practices
• Develop an operational plan for each medical practice to deploy office personnel and coordinate with Healthy Blue resources to optimize performance on targeted quality measures and to improve clinical and cost outcomes for members identified to have high clinical risk
• Coordinate scheduling of high risk members and those having HEDIS gaps for appointments
• Communicate with medical office personnel about identified gaps in care that will be apparent to the practitioner at the patient encounter
• Meet with physicians and other clinical personnel to problem solve and develop engagement plans for high risk members
• Work with practitioners and office staff to improve documentation of diagnoses, including specific manifestations, facilitate access of members to Healthy Blue case management, population health, and behavioral health programs as indicated, and help coordinate services provided by practice and Healthy Blue personnel
• Serve as the subject matter expert for primary care practices on all Healthy Blue clinically focused program
• Conduct periodic meetings with each practice to track progress towards implementing the project plan and attaining goals established in the engagement contract
• Support the Healthy Blue Provider Collaboration Lead in organizing and implementing support to achieve targeted revenue, medical expense, and quality goals for the assigned region 
• Assures compliance to practice guideline, delegation and continuity and coordination of care standards 
• Provides oversight to assure accurate and complete quantitative analysis of clinical data and presentation of results. 

Qualifications

Requires: 

• BA/BS in Nursing 
• Minimum 5 years of clinical experience 
• Demonstrated commitment to clinical quality improvement  
• Unrestricted RN license in the state of North Carolina
• This position requires field work, visiting providers, approximately 75% of the time.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2019 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran. 

Clipped from: https://anthemcareers.ttcportals.com/jobs/6131116-provider-clinical-liaison-north-carolina-medicaid?tm_job=PS43677&tm_event=view&tm_company=2522&bid=370

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.

Director – Network Management (Contracting)

Responsible for network development and provider reimbursement for the Statewide  Health Services Area. Primary duties may include, but are not limited to: Oversees contracting and maintenance of all facilities including hospitals, surgery centers, etc. Oversees the development, maintenance and reconciliation of physician risk contracts and capitated arrangements. Attracts, develops and manages key contracting staff. Develops innovative strategies to maintain a cost effective network with adequate access and positive working relationships with providers. Hires, trains, coaches, counsels, and evaluates performance of direct reports. 

Qualifications

• BS/BA degree in business administration or related healthcare field
• 8-10 years’ healthcare operations, finance, underwriting, actuary, network development and sales experience; or any combination of education and experience, which would provide an equivalent background.

Preferences:

• CPA or MBA 
• Comprehensive knowledge and understanding of managed care principles and practices, experience in fee for service, value based payment models, hospital, complex health systems, physician and ancillary provider types
• Demonstrated track record of success in negotiating with providers including preparation and design of the negotiation as well as execution
• Proven ability to prepare and present managed care strategies
• Demonstrated analytical skills, including financial modeling and reimbursement technologies
• Knowledge of payer and hospital/physician managed care operations
• Demonstrated knowledge of Federal and State Regulations, including Medicare, Medicaid

Clipped from: https://anthemcareers.ttcportals.com/jobs/6034009-director-network-management-contracting