Category: Curator- Job Hunter

 
 

Resp & Qualifications

Position Summary

The Claims Examiner is responsible for the accurate and timely processing of claims per regulatory and contractual guidelines.

Essential Duties and Responsibilities

• Responsible for accurate and timely adjudication of claims according to guidelines.
• Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue and ICD-10 codes, under the correct provider and member benefits, i.e. co-payments, deductibles, etc.
• Claims processing based upon contractual agreements, involving the use of established payment methodologies.
• Alerts manager or supervisor of issues that impact production and quality, i.e. incorrect database configurations, non-compliant claims, etc.
• Process claims based on compliance regulation and timeframes.
• Process both professional (CMS-1500) and facility (UB-04) claim types.
• Maintain quality and productivity standards as set by management.
• Review services for appropriateness of charges and apply authorization guidelines during claims processing.
• Other duties as assigned by management.

Education, Experience and Qualifications

• High School graduate or equivalent.
• 2-3 years’ experience processing on-line claims in a managed care and/or PPO/indemnity environment.
• Experience processing Medicare or Medicaid claims preferred.
• Customer service and organizational skills required.
• Experience with HealthRules Payor preferred. 

Knowledge, Skills and Abilities

• Revenue Codes, CPT-4/HCPCS, ICD-10 codes.
• Industry pricing methodologies, such as RBRVS, Fee Schedule, DRG, etc.
• Medical terminology.
• Benefit interpretation and administration.

Computer Skills

• Microsoft Office including Share Point, Outlook, Excel and Word

Department

Department: MD Medicaid -CLAIMS

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: 8/11/21

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://carefirstcareers.ttcportals.com/jobs/7155180-claims-examiner-md-medicaid-and-medicare?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Description:

**Description**


The Medicaid State Implementation Lead provides support to existing and new Medicaid implementations.


**Responsibilities**


The Medicaid State Implementation Lead works on projects of diverse scope and complexity with potential revenue projections over a Billion dollars. Critical thinking is required and this position is responsible for being a thought leader able to influence change and implement large-scale programs.


+ Develop internal and external partnerships and related strategies to meet requirements of varying dual eligible and Medicaid models.


+ Work collaboratively with a variety of cross-functional teams and thought leaders to deliver committed program capability.


+ New Business Development – primary responsibilities include:


+ As a representative of the Medicaid Implementation team, provide strategic leadership as we evaluate market entry strategies in pipeline markets and respond to Requests for Proposals for new lines of business.


+ Participate in the RFP Response process along with the Business Development team working closely with cross-functional Medicaid leaders to shape the Strategy and commitments.


+ Identify new and innovative opportunities and programs and work across the Medicaid leadership team to develop a plan to implement them.


+ New State and/or contract re-procurements – primary responsibilities include:


+ Developing and executing on the end-to-end business implementation model


+ State relationship management throughout the implementation process


+ Support new Market resources upon onboarding


+ Participate in business requirements sessions ensure all requirements are accounted for including maintenance and requirements tractability. .


+ Implementation Schedule creation and maintenance


+ Executive summary status reporting and issue/risk escalation


+ Owns key Project Meetings with Stakeholders and Leadership.


+ Actively participate in Business Readiness Validation and State Readiness Review.


+ Ensure compliance with coordinating CMS and State Medicaid regulations.


**Required Qualifications:**


+ Bachelor’s degree or equivalent experience.


+ 3 – 5 years’ experience with Medicaid/Medicare operations/healthcare experience.


+ 5 – 7 years managing large scale projects and cross functional teams.


+ Success in developing working relationships within a highly matrixed business environment.


+ Ability to analyze data and make informed recommendations.


+ Experience managing and facilitating with the ability to influence without having authority.


+ Act as a thought leader with strong verbal and written communication skills (ability to interact effectively with people at all levels within a team or internal division).


+ Strong critical thinking, problem solving skills; detailed and well organized.


+ Demonstrates accuracy and thoroughness, identifies process improvements, fosters quality in others.


+ Accepts responsibility, is self-motivated and accountable for achieving implementation and market satisfaction goals.


+ Works within deadlines, demonstrates independence, resourcefulness and self-management skills.


+ Works well within an ambiguous environment where direction is always subject change.


+ Ability to flow to the work as capacity demands change.


**Preferred Qualifications:**


+ Master’s degree.


+ Experience responding to state and/or federal government solicitations.


+ Knowledge of Humana’s internal policies, procedures and systems.


**Scheduled Weekly Hours**


40

 
 

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Job Description

With over 100 offices and nearly 5,000 associates in major metropolitan areas and suburban cities throughout the U.S. CBIZ (NYSE: CBZ) delivers top-level financial and employee business services to organizations of all sizes, as well as individual clients, by providing national-caliber expertise combined with highly personalized service delivered at the local level.   

CBIZ has been honored to be the recipient of several national recognitions: 
 


•    2020 Best Workplaces in Consulting & Professional Services by Great Place to Work®


•    2020 Workplace Excellence Seal of Approval by the Alliance for Workplace Excellence


•    Top 101 2020 Best and Brightest Companies to Work For in the Nation


•    2020 Healthiest 100 Workplace in America


•    2021 Top Workplaces USA

CBIZ Benefits & Insurance Services is a division of CBIZ, Inc., providing benefits consulting, HRIS technology, payroll, human capital management, property and casualty, talent and compensation solutions, and retirement plan services to organizations of all sizes. CBIZ is ranked as a Top 20 Largest Broker of U.S. Business (Business Insurance Magazine) and a Top 100 Retirement Plan Adviser (PLANADVISER).

Essential Functions and Primary Duties:
 

• Assisting patients in applying for financial assistance through Medicaid on behalf of our client facility.
• Interviewing patients or authorized representatives via phone or in person to gather information to determine eligibility for medical benefits.
• Obtaining, verifying, and calculating income and resources to determine client financial eligibility.
• Documenting case records using automated systems to form a record for each client.
• Following up with applicants to obtain accurate and complete information within strict timeframes.
• Completing/following up on all forms related to Medicaid eligibility.
• Performing any additional tasks related to the position assigned by the Manager.

 Preferred Qualifications:
 

• Bachelor’s degree. 
• Knowledge of Medicaid and Charity Care.
• Experience working in a hospital environment.
• Ability to speak and read Spanish.

Minimum Qualifications:
 

• High school diploma/GED.
• Must be ambitious and self-directed in a fast-paced environment and can perform in a high volume, multitasking setting.
• Must be trustworthy, professional, detail and goal oriented.
• Must have exceptional customer service and excellent verbal/written communication skills.
• Must be able to learn and work with Medicaid eligibility regulations.

 
 

Clipped from: https://careers.cbiz.com/en-US/job/medicaid-eligibility-specialist/J3P0X764PBQC0QFQ7V3?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

APPLICATION INSTRUCTIONS:

Resumes for the position must be sent to resumes@oag.ok.gov and
indicate which particular position is being applied for in the subject line of the email.
———————————————————————————————-

Location:  Tulsa, OK  

Position Summary:
The Medicaid Fraud Control Unit of the Oklahoma Attorney General’s Office is seeking an Agent whose primary responsibilities will be to investigate Medicaid fraud.  The Medicaid Fraud Control Unit investigates and prosecutes Medicaid fraud; as well as abuse, neglect, exploitation and drug diversion in long-term board and care facilities.

Qualifications: 
Applicants must be CLEET certified.  Preference will be given to applicants with experience in investigations, interviewing techniques and report writing.  Knowledge of computer software applications such as Excel, Word and Microsoft Office Suite is required.  A valid Oklahoma Driver’s license and the ability to travel is required.

All applicants must agree in writing to complete, and satisfactorily pass, a background investigation by the Office of the Attorney General.

The Oklahoma Office of Attorney General is an equal employment employer. All individuals are welcome to seek employment with the Oklahoma Office of Attorney General regardless of race, sex, sexual orientation, gender identity, color, age, national origin, genetic information, religion, or disability, so long as the disability does not render the person unable to perform the essential functions of the position for which employed with or without a reasonable accommodation. All employees of the Oklahoma Office of Attorney General are “at will” employees.

 
 

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Department of Health And Human Services

Center for Medicare & Medicaid Innovation (CMMI)

This position is located in the Department of Health & Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Center for Medicare and Medicaid Innovation, Learning and Diffusion Group (LDG), Division of Model Learning Systems (DMLS).


As a Supervisory Health Insurance Specialist (Division Director), GS-0107-15, you will provide leadership and executive direction for implementing assigned programs within the Division of Model Learning System (DMLS).

Learn more about this agency

Responsibilities

• Directs the activities necessary to ensure the successful completion of planning, development, and implementation of new and/or innovative program management for DMLS based heavily in continuous improvement and Human Centered Design (HCD).
• Ensures that the principles of quality management are assimilated into the work environment by identifying work barriers and developing ways to reduce them, promoting team building, and improving work processes.
• Uses data to conduct, assess, and evaluate HCD, quality improvement, and innovation initiatives.
• Monitors complex technical and operational aspects of programs and projects using HCD to ensure successful completion.
• Directs activities with internal and external stakeholders, including senior level officials from the Department of Health and Human Services (HHS).

Travel Required

Occasional travel – You may be expected to travel up to 5% for this position.

Supervisory status

Yes

Promotion Potential

15

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Requirements

Conditions of Employment

• You must be a U.S. Citizen or National to apply for this position.
• You will be subject to a background and suitability investigation.
• Time-in-Grade restrictions apply.

Qualifications

ALL QUALIFICATION REQUIREMENTS MUST BE MET WITHIN 30 DAYS OF 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-15, 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-14 grade level in the Federal government, obtained in either the private or public sector, to include:
(1) Utilizing a human centered design or equivalent approach to develop projects or studies related to improving healthcare initiates or treatment; AND (2) Planning, organizing, or assessing work activities for employees or teams to ensure that program operational goals are met; AND (3) Coordinating projects that aim to improve quality and access of a healthcare program.


Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., 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.


Time-in-Grade: To be eligible, current Federal employees must have served at least 52 weeks (one year) at the next lower grade level from the position/grade level(s) to which they are applying.

Click the following link to view the occupational questionnaire: https://apply.usastaffing.gov/ViewQuestionnaire/11168040

Education

This job does not have an education qualification requirement.

Additional information

Bargaining Unit Position: No

Tour of Duty: Flexible

Recruitment/Relocation Incentive: Not Authorized

Financial Disclosure: Not Required


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.


Additional Forms REQUIRED Prior to Appointment:

• Optional Form 306, Declaration of Federal Employment and the Background/Suitability Investigation – A background and suitability investigation will be required for all selectees. Appointment will be subject to the successful completion of the investigation and favorable adjudication. Failure to successfully meet these requirements may be grounds for appropriate personnel action. In addition, if hired, a reinvestigation or supplemental investigation may be required at a later time. If selected, the Optional Form 306 will be required prior to final job offer. Click here to obtain a copy of the Optional Form 306.
• Form I-9, Employment Verification and the Electronic Eligibility Verification Program – CMS participates in the Electronic Employment Eligibility Verification Program (E-Verify). E-Verify helps employers determine employment eligibility of new hires and the validity of their Social Security numbers. If selected, the Form I-9 will be required at the time of in-processing. Click here for more information about E-Verify and to obtain a copy of the Form I-9.
• Standard Form 61, Appointment Affidavits – If selected, the Standard Form 61 will be required at the time of in-processing. Click here to obtain a copy of the Standard Form 61.

If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application.

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How You Will Be Evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

Once the announcement has closed, your online application, resume, and CMS required documents will be used to determine if you meet eligibility and qualification requirements listed on this announcement. If you are found to be among the top qualified candidates, you will be referred to the selecting official for employment consideration. Please follow all instructions carefully. Errors or omissions may affect your rating.


Your qualifications will be evaluated on the following competencies (knowledge, skills, abilities and other characteristics):

• Building Coalitions/Communications
• Business Acumen
• Leading People
• Managing Change
• Results Driven

Additional selections may be made from this announcement for similar positions within CMS in the same geographical location. For Central Office vacancies, the “same geographical location” includes Baltimore, Maryland; Bethesda, Maryland; and Washington, D.C.

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Background checks and security clearance

Security clearance

Not Required

Drug test required

No

Position sensitivity and risk

Moderate Risk (MR)

Trust determination process

Credentialing, Suitability/Fitness

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Required Documents

The following documents are REQUIRED:


1. Resume
showing relevant experience; cover letter optional. Your resume must indicate your citizenship and if you are registered for Selective Service if you are a male born after 12/31/59. Your resume must also list your work experience and education (if applicable) including the start and end dates (mm/yyyy) of each employment along with the number of hours worked per week. For work in the Federal service, you must include the series and grade level for the position(s). Your resume will be used to validate your responses to the assessment tool(s). For resume and application tips visit: https://www.usajobs.gov/Help/faq/application/documents/resume/what-to-include/

2. CMS Required Documents (e.g., SF-50, DD-214, SF-15, etc.). Current CMS employees are REQUIRED to submit a copy of their most recent Notification of Personnel Action (SF-50) at the time of application. Additional documents may also be required to be considered for this vacancy announcement. Click here for a detailed description of the required documents. Failure to provide the required documentation WILL result in an ineligible rating OR non-consideration.


PLEASE NOTE: A complete application package includes the online application, resume, and CMS required documents. Please carefully review the full job announcement to include the “Required Documents” and “How to Apply” sections. Failure to submit the online application, resume and CMS required documents, will result in you not being considered for employment.

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Benefits

A career with the U.S. Government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.

Review our benefits

Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time, or intermittent. Contact the hiring agency for more information on the specific benefits offered.

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How to Apply

Your complete application package, as described in the “Required Documents” section, must be received by 11:59 PM ET on 07/19/2021 to receive consideration.


IN DESCRIBING YOUR WORK EXPERIENCE AND/OR EDUCATION, PLEASE BE CLEAR AND SPECIFIC REGARDING YOUR EXPERIENCE OR EDUCATION.


We strongly encourage applicants to utilize the USAJOBS resume builder in the creation of resumes. Please ensure EACH work history includes ALL of the following information:

• Official Position Title (include series and grade if Federal job)
• Duties (be specific in describing your duties)
• Employer’s name and address
• Supervisor name and phone number
• Start and end dates including month and year (e.g. June 2007 to April 2008)
• Full-time or part-time status (include hours worked per week)
• Salary

Determining length of general or specialized experience is dependent on the above information and failure to provide ALL of this information WILL result in a finding of ineligible.

• To begin, click Apply to access the online application. You will need to be logged into your USAJOBS account to apply. If you do not have a USAJOBS account, you will need to create one before beginning the application.
• Follow the prompts to select your resume and/or other supporting documents to be included with your application package. You will have the opportunity to upload additional documents to include in your application before it is submitted. Your uploaded documents may take several hours to clear the virus scan process.
• After acknowledging you have reviewed your application package, complete the Include Personal Information section as you deem appropriate and click to continue with the application process.
• You will be taken to the online application which you must complete in order to apply for the position. Complete the online application, verify the required documentation is included with your application package, and submit the application.

To verify the status of your application, log into your USAJOBS account (https://my.usajobs.gov/Account/Login), all of your applications will appear on the Welcome screen. The Application Status will appear along with the date your application was last updated. For information on what each Application Status means, visit: https://www.usajobs.gov/Help/how-to/application/status/.


This agency provides reasonable accommodation to applicants with disabilities. If you need a reasonable accommodation for any part of the application or hiring process, please send an email to breanna.wells2@cms.hhs.gov. The decision to grant reasonable accommodation will be made on a case-by-case basis.


Commissioned Corps Officers (including Commissioned Corps applicants that are professionally boarded) who are interested in applying for this position must send their professional resume (not PHS Curriculum Vitae) and cover letter to CMSCorpsJobs@cms.hhs.gov in lieu of applying through this announcement. The cover letter should specifically explain how you are qualified for this position and draw specific attention to your resume that demonstrates these qualifications. Also send any transcripts, licenses or certifications as requested in this announcement. In the subject line of your e-mail please include only the Job Announcement Number. In the body of your e-mail please include your current rank name and serial number. Failure to provide this information may impact your consideration for this position.


CMS employees who are currently appointed under Schedule A authority and are interested in applying for this position must submit their resume, Schedule A documentation, transcripts (if positive education required or qualifying through education substitution), and cover letter (optional) to breanna.wells2@cms.hhs.gov. You MUST include the Job Announcement Number in the subject line of the email to receive consideration for the position. For additional information regarding Schedule A authority click here.

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Agency contact information

Breanna Wells

Email

breanna.wells2@cms.hhs.gov

Address

Center for Medicare and Medicaid Innovation
7500 Security Blvd
Woodlawn, MD 21244
US

Learn more about this agency

Next steps

Once your online application is submitted, you will receive a confirmation notification by email. Your application will be evaluated to determine your eligibility and qualifications for the position. After the evaluation is complete, you will receive another email notification regarding the status of your application.


Within 30 business days of the closing date,07/19/2021, you may check your status online by logging into your USAJOBS account (https://my.usajobs.gov/Account/Login). We will update your status after each key stage in the application process has been completed.

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• Fair & Transparent

The Federal hiring process is setup to be fair and transparent. Please read the following guidance.

Equal Employment Opportunity Policy

The United States Government does not discriminate in employment on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an employee organization, retaliation, parental status, military service, or other non-merit factor.

• Equal Employment Opportunity (EEO) for federal employees & job applicants

Read more

Reasonable Accommodation Policy

Federal agencies must provide reasonable accommodation to applicants with disabilities where appropriate. Applicants requiring reasonable accommodation for any part of the application process should follow the instructions in the job opportunity announcement. For any part of the remaining hiring process, applicants should contact the hiring agency directly. Determinations on requests for reasonable accommodation will be made on a case-by-case basis.

A reasonable accommodation is any change to a job, the work environment, or the way things are usually done that enables an individual with a disability to apply for a job, perform job duties or receive equal access to job benefits.

Under the Rehabilitation Act of 1973, federal agencies must provide reasonable accommodations when:

• An applicant with a disability needs an accommodation to have an equal opportunity to apply for a job.
• An employee with a disability needs an accommodation to perform the essential job duties or to gain access to the workplace.
• An employee with a disability needs an accommodation to receive equal access to benefits, such as details, training, and office-sponsored events.

You can request a reasonable accommodation at any time during the application or hiring process or while on the job. Requests are considered on a case-by-case basis.

Learn more about disability employment and reasonable accommodations or how to contact an agency.

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Legal and regulatory guidance

• Financial suitability
  
• Social security number request
• Privacy Act
• Signature and false statements
• Selective Service
• New employee probationary period

 
 

 
 

Clipped from: https://www.usajobs.gov/GetJob/ViewDetails/607196700?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Description:

If you are a job seeker with a disability and require a reasonable accommodation to apply for one of our jobs, you will find the contact information to request the appropriate accommodation by visiting the following page:

Director, Medicaid and SNP Product & Strategy Description

This position is responsible for assigned Medicaid and SNP product portfolio development and management. The Director will design, implement, maintain, document and analyze current Medicaid and SNP plans, as well as identify, prioritize and develop strategy for product expansion to continuously improve Medica’s Medicaid and SNP market position while working to align products and program offerings with state procurement cycles.

This role will work closely with Medicaid and SNP segment leadership, actuarial, network, sales, operations, marketing, and physician & health services to develop and communicate product intent, and ensure accurate and complete understanding and administration both internally, in the marketplace and with state and federal regulators. 

Incumbent must have a proven track record with Medicaid and SNP products and understand the operational, clinical and financial implications of plan designs. Director is subject matter expert on Medicaid and SNP plan performance including membership, income, and operating margin. Position will also implement and manage strategic partnerships, alternative payment arrangements and external vendors.

Qualifications:

• Bachelor’s degree or equivalent combination of education and experience required
• 10+ years Medicaid, Medicare or SNP experience with a track record of successfully leading growth initiatives
• 5+ years leadership experience required 
• Medicaid and SNP Products plan benefit design, bid development and operational implementation

Specific types of experience or skills required:

• Product performance monitoring, establishing metrics to measure product success
• CMS and DHS compliance and understanding of MCO regulatory environment
• Health plan operations understanding
• Analytical ability in business planning and financial management
• Demonstrated leadership and influencing skills with the ability to lead and drive change
• Strong communication and presentation skills
• Strong strategic planning skills
• Financial performance measurement skills, accountable for results
• Ability to articulate vision and strategy
• Passionate about member experience and recognized as a positive change agent who can work effectively in creating direction and influence to effective results
• Team player with strong relationship building skills at all levels of the organization and externally
• Creative problem solving skills using innovative approaches
• Ability to handle multiple complex projects with a high degree of engagement
• Strong drive for results and accountability
• Expertise in project development and implementation management

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor 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. However, 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 contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)

3 days ago

 
 

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Overview


About Public Consulting Group


Public Consulting Group, Inc. (PCG) is a leading public sector solutions implementation and operations improvement firm that partners with health, education, and human services agencies to improve lives. Founded in 1986 and headquartered in Boston, Massachusetts, PCG has over 2,500 professionals in more than 60 offices worldwide. PCG’s Technology Consulting practice offers a full spectrum of quality Information Technology (IT) services to help state and local government agencies at every stage of the IT life cycle. Through its specialized IT services, PCG’s Technology Consulting team finds cost-effective ways to help agency partners deliver successful IT systems that enhance the lives of the user base. To learn more, visit https://www.publicconsultinggroup.com/technology-consulting/

Responsibilities

• Provide Medicaid program operations subject matter expertise and business requirements analysis on large-scale IT projects.
• Work with clients to provide consulting support (e.g., policy expertise, requirements validation, technical support).
• Create Medicaid system applications, eligibility, and enrollment system test cases and identify appropriate test case parameters
• Review vendor test cases to verify Medicaid policy requirements coverage
• Work with client project staff to understand and verify documentation of system requirements.
• Perform project assessments in support of IV&V and quality assurance projects, including providing recommendations for risk mitigation and acceptance.
• Monitor the technical aspects of the project and the vendor and/or client activities providing input and guidance that supports efficiencies to the client and project.
• Understand various software development life cycle methodologies and how they are used
• Oversees development of all deliverables, monthly reports and other work products
• Maintain project plans and schedules
• Participate in business development by identifying new opportunities and assisting with proposal development
  
  

Qualifications


Required Skills/Experience:

• Self-directed and comfortable working directly with clients to determine needs, clarify tasks and expectations, and present work products and findings
• 3+ years of business analysis experience
• Bachelor’s degree from an accredited college/university
• 3+ years of experience in Medicaid program application, eligibility, and enrollment operations and policy
• Knowledge and experienced in business requirements validation and test case creation and review (e.g., verification of requirements coverage)
• Demonstrated ability to work cooperatively within and among teams
• Jackson, MS local
  
  

Desired Skills/Experience

• Experience providing IV&V services or similar oversight activities (e.g., QA).
• Completed Project Management Institute (PMI) Project Management Professional (PMP) certification, or similar Project Management certification.
  
  

#D-PCG

EEO Statement

Public Consulting Group is an Equal Opportunity Employer dedicated to celebrating diversity and intentionally creating a culture of inclusion. We believe that we work best when our employees feel empowered and accepted, and that starts by honoring each of our unique life experiences. At PCG, all aspects of employment regarding recruitment, hiring, training, promotion, compensation, benefits, transfers, layoffs, return from layoff, company-sponsored training, education, and social and recreational programs are based on merit, business needs, job requirements, and individual qualifications. We do not discriminate on the basis of race, color, religion or belief, national, social, or ethnic origin, sex, gender identity and/or expression, age, physical, mental, or sensory disability, sexual orientation, marital, civil union, or domestic partnership status, past or present military service, citizenship status, family medical history or genetic information, family or parental status, or any other status protected under federal, state, or local law. PCG will not tolerate discrimination or harassment based on any of these characteristics. PCG believes in health, equality, and prosperity for everyone so we can succeed in changing the ways the public sector, including health, education, technology and human services industries, work.

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In this role, you will be defining and designing program enhancements to support the expansion of CareCentrix products into government programs with a focus on home health care and provider reimbursement models. You will serve as the key liaison between product management, operations and development teams to ensure that CareCentrix products are designed to deliver on the intended value and ongoing expansion into government programs. This position will work closely with product development and corporate compliance to assure all product development initiatives are compliant with Federal, State, and other relevant regulatory requirements.

 
 

In this role you will be:

• Responsible for leading product/program development projects related to the expansion of government programs within the CareCentrix product portfolio; including the development of a product concept/vision, success metrics, and business requirements to deliver on intended value/objective.
• Lead cross-functional teams and drive execution of product enhancements to support the expansion of government programs through concept assessment, design, development, and launch.
• Define/design enhancements to utilization management and clinical programs to enhance the value with quality outcomes for government programs, patients and health care providers.
• Ensure business requirements are accurately identified in alignment with current product framework and capabilities; including the identification of new product opportunities.

 
 

You should reach out if:

 
 

• You have a Bachelor’s Degree (preferred) or equivalent experience.
• You have 7+ years in home healthcare product development and in depth knowledge of the health care marketplace including government programs (Medicare Advantage and Managed Medicaid) and value based pricing methodologies, such as episodic payment models.
• You have developed and managed value based or PDGM home health billing programs.
• You have work experience in execution of product development.
• You have the ability to lead and direct cross-functional / matrix team.
• Advanced proficiency in Microsoft Excel, PowerPoint, Visio, MS Project

 
 

What we offer:

• Full range of benefits including Health, Dental and Vision with HSA Employer Contributions and Dependent Care FSA Employer Match.
• Generous PTO, 401K Savings Plan, Paid Parental Leave, free on-demand Virtual Fitness Training and more.
• Advancement opportunities, professional skills training, and tuition Reimbursement
• Great culture with a sense of community.

 
 

CareCentrix maintains a drug-free workplace.

 
 

We are an equal opportunity employer. Employment selection and related decisions are made without regard to age, race, color, national origin, religion, sex, disability, sexual orientation, gender identification, or being a qualified disabled veteran or qualified veteran of the Vietnam era or any other category protected by Federal or State law.

PI137635210

 
 

Clipped from: https://www.linkedin.com/jobs/view/director-design-product-development-medicaid-medicare-at-carecentrix-2616845217/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Staff Pharmacist, Population Health, Managed Medicaid

SCHEDULE: 1st shift (0800-1630) subject to change based on needs. Mon-Fri, 40 hours weekly

JOB DESCRIPTION: This Staff Pharmacist will support the population health management program for Managed Medicaid. The Pharmacist will be responsible for providing frontline, direct contact with patients, pharmacies and providers primarily through phone or telehealth encounters. Pharmacy services will be designed to target adherence strategies, high cost disease states, medication therapy management, polypharmacy, education and counseling services, escalation strategies for specialty disease states and additional medication access needs. This role will also help optimize drug utilization from a cost-minimization standpoint, and may facilitate access to additional services, both within and outside the medical center. The Pharmacist will have direct contact with areas both within and external to the pharmacy department such as the population health team, pharmacy care clinic, Managed Medicaid care management system (Emtiro), retail and specialty pharmacies, social work, ambulatory care navigators, and healthcare providers. This individual must have strong problem-solving, emotional intelligence, creativity, written and verbal communication, data analysis, data interpretation and data entry skills. This individual must also be able to quickly adapt to change and maintain a positive attitude. This individual, like all department employees, will be expected to uphold the hospital’s key values and to be a team player at all times.

EDUCATION/EXPERIENCE:

• Graduate of an accredited School of Pharmacy with a B.S. in Pharmacy or Pharm. D. degree is required.
• Completion of a Residency Program with at least 1 year of experience preferred.
• Board Certification preferred.
• Managed care experience preferred; community, specialty or ambulatory care experience preferred.

LICENSURE, CERTIFICATION, and/or REGISTRATION:

• Active Registration with North Carolina Board of Pharmacy required.

ESSENTIAL FUNCTIONS:
1. Processes medication orders and prescriptions ordered by physicians or nurses for patients.
2. Supervises the work of technicians to ensure that correct medications are provided for patients on time, and support staff is fully utilized to meet area needs.
3. Provides pharmaceutical care to patients to achieve optimal therapeutic outcomes.
4. Participates in the team approach to quality improvement to support the Pharmacy Department’s commitment to the philosophy and principles of Total Quality.
5. Updates knowledge and skills of self and other health care professionals to maintain, improve and document competency.
6. Documents activities to provide information needed to meet standards, regulations, laws and/or other administrative requirements.
7. Participates in planning by establishing personal goals to support quality improvement efforts and contribute to the achievement of departmental objectives.
8. Provides age/developmental appropriate care in accordance with Age/Development Specific Guidelines for the age groups served when participating in patient care.
9. Adheres to the general hospital standards to promote a cooperative work environment by utilizing communication skills, interpersonal relationships and team building.

SKILLS/QUALIFICATIONS:

• Ability to communicate on a professional level with physicians, nurses and other professional staff when discussing drugs and drug related problems
• Strong oral and written communication
• Contact with patients, family members, visitors, coworkers and medical staff under a wide variety of circumstances
• Excellent customer service skills

WORK ENVIRONMENT:

• Potential exposure to infections and contagious diseases
• Handles emergency or crisis situations
• Possible exposure to latex
• Possible exposure to cytotoxic (chemotherapeutic) agents
• Requires judgment/action that could result in death of patients
• Noise generated from telephones, computers/printers, hood and verbal communication
• Possible exposure to the risk of bloodborne and/or airborne pathogens
• Subject to many interruptions
• Pressure due to multiple demands
• Subject to changes in work schedules and areas to meet customer/department needs

To apply for this position, please click on the “Apply Now” button on this page. You must complete the application process and then submit your application by clicking on the “Submit” button located at the bottom of the page titled “Submit Online Application”. You will receive the following message once you hit the submit button: “You have successfully submitted your job application”.

Computers are available for applying within the lobby of the Human Resources Department located at 1920 West First Street, (on the corner of Miller and First Street) Winston-Salem, North Carolina 27104. You may also call our office for assistance at (336) 716-6464. Office hours are Monday-Friday, 8:00am-5:00pm.

If you are an individual with a disability and need reasonable accommodation to participate in the application process, please contact our Supervisor of Office Services by phone (336) 716-3367 or email at accommodationrequest@wakehealth.edu.

It is the policy of Wake Forest Baptist Medical Center to administer all educational and employment activities without discrimination because of race, sex, age, religion, national origin, disability, sexual orientation, gender identity or veteran status (except where sex is a bona fide occupational qualification or a statutory requirement) in accordance with all local, state, national laws, executive orders, regulations, and guidelines.

 
 

Clipped from: https://www.glassdoor.com/job-listing/staff-pharmacist-population-health-managed-medicaid-wake-forest-baptist-medical-center-JV_IC1139151_KO0,51_KE52,86.htm?jl=4065926750&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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.

Pharmacist Program Manager

*Open to other locations however, the individual is preferred to live in an Eastern Time Zone area. 

The Pharmacist Program Manager is responsible for serving as the primary contact for the BCBS WNY Medicaid pharmacy program.

Primary duties include but are not limited to:

• Represent BCBS WNY Medicaid pharmacy program for the region, externally;

 
 

• Face of plan to Government Relations, NYS DOH
• Attend state meetings, respond to email inquiries

• Represent BCBS WNY Medicaid pharmacy program within the health plan and with PBM vendor
• Maintain, enhance and modify components of the pharmacy program as needed to align with health plan goals and pharmacy program national Medicaid best practice 
• Prepare and present routine pharmacy program updates within various forums, including but not limited to: quarterly business reviews, regulatory meetings, quality meetings to support accreditation, biweekly trend meetings
• On occasion solve claims issues and complaints with the support of Pharmacy Operations team or Medicaid Account Management team
• Perform routine benefit surveillance to assure benefits are working correcting, optimal penetration of preferred products, low claim reject volumes
• Assure successful implementation of program changes including: state mandates and programs to improve the member and provider experience, contain costs and improve quality of service
• Present and report on Enterprise quality programs that impact the market

 
 

• Advocate for plan needs
• Identify, develop, and/or advocate for quality programs that will drive more favorable withhold measures (local, enterprise)
• Report on the productivity and outcomes of clinical quality programs

• Assure appropriate access for health plan staff to RX tools
• Assure all necessary client/vendor accountability reporting is complete, accurate an on time.
• Develop and implement communications to pharmacies, prescribers and members as necessary to improve member and provider experience and reduce cost

Qualifications

Qualifications 

• Requires a registered pharmacist; 2 years of managed care pharmacy experience including knowledge of current health care and managed care pharmacy practices; or any combination of education and experience, which would provide an equivalent background. 
• Current state license to practice pharmacy as a RPH required. 
• Minimum 2 years of managed care pharmacy experience that is NOT RETAIL PHARMACY related preferred
• Proficiency in MS Excel, Power Point, Outlook
• Program Management experience in managed care or other related field
• Must demonstrate proficiency as a key participant in program development, where the program seeks to satisfy regulatory requirements, improve clinical outcomes, quality, cost or other measure.
• Must demonstrate proficiency in clinical/technical communication to business leaders, an ability to communicate messages pertaining to programs and systems using data and other details in a way business leaders can understand
• Professional designation preferred
• Day travel and occasional overnight travel may be required
• Experience with government programs (Medicare/Medicaid) 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. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 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/6985076-pharmacist-program-manager-slash-wny-medicaid-plan?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic