**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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Washington State Olympia,

legal assistant medicaid fraud people neglect legal support assessment accommodation

Description**Persons requiring reasonable accommodation in the application process or requiring information in an alternative format may contact Kalea Muigai at 360-586-7698. Those with a hearing impairment in need of accommodation are encouraged to contact the Washington Relay Service at 1-800-676-3777 or ****_www.washingtonrelay.com_****.****_Agency Information_**The AGO serves more than 230 state agencies, boards, commissions, colleges and universities, as well as the Legislature and the Governor. The mission of the Office is to deliver the highest quality professional legal services to officials, agencies, and citizens of the state of Washington. The Office is comprised of over 550 attorneys and 700 professional staff. Diversity is critical to the success of the mission of the AGO. It is the recognition, respect, and appreciation of all cultures and backgrounds and the fostering of the inclusion of differences between people. Appreciating, valuing and implementing principles of diversity permits AGO employees to achieve their fullest potential in an inclusive, respectful environment. The core values of the AGO are served by a strong commitment to the value of diversity and by promoting an inclusive workplace.For more information about the AGO, we encourage you to review the Office’s newest Annual Report which can be found HERE and view THIS VIDEO**.**The Attorney General’s Office is recruiting for two permanent full time _Legal Assistant 3_ positions in the Medicaid Fraud Control Division. This position is located in Olympia, Washington. This position is represented by the Washington Federation of State Employees (WFSE).This recruitment announcement may be used to fill multiple open positions for the same classification, in addition to the position(s) listed in this announcement.The work of the Office’s Medicaid Fraud Control Division (MFCD) focuses on both criminal and civil law enforcement. At this time, we have a Legal Assistant 3 position available. This position provides assistance to MFCD assistant attorney’s general, investigators, paralegals and financial analysts assigned to investigate and help litigate criminal actions, civil and dual track actions involving Medicaid provider fraud and abuse and neglect at Medicaid funded facilities. The 75% federally funded MFCD’s mission is combating provider fraud as well as abuse and neglect in residential facilities.MFCD’s Headquarters is located in Olympia, Washington with some team members also located at the AGO’s Spokane Office and Seattle Office. The Division currently has a staff of 58 FTEs, including attorneys, auditors, investigators, data analysts and professional support staff.MFCD involves protecting not only the Medicaid program of roughly 13 billion dollars per annum, but also its most vulnerable persons, typically elderly nursing home patients and Medicaid recipients in any setting. In many of our cases, there is no precedent so MFCD is consistently on the cutting edge of legal theories and issues. The cases range from abuse and neglect of persons in nursing homes, large scale organized individual and corporate civil and criminal fraudulent activity to national whistleblower actions. Our staff is a highly professional, fun and seasoned analytical investigative team. MFCD is unique in that all cases have an attorney, investigator and data analyst assigned. This, and the great people who make up the unit, gives MFC a particularly terrific team atmosphere.DutiesIn support of AAG(s), performs complex legal assistant duties at the senior level under general direction performs complex legal support functions; trains, leads and/or mentors lower level staff and serves as a resource for staff regarding technical legal assignments.Under general direction performs complex legal support functions such as: identifying and pursuing next steps in litigation or adjudication process; verifying legal citations and references for accuracy, consistency, and case relevance; composing correspondence for signature; properly formatting, preparing, processing, filing, citation verification, and serving documents before federal, state, local, and appellate courts and upon parties to the case.Applies specialized knowledge of various court rules related to legal practice subject matter and court filing procedures and is a liaison with prosecutor’s offices, court clerks, and other agencies statewide.Reviews work product of lower level legal staff for accuracy, completeness, and compliance with agency procedures and court rules. Provides training to other legal staff in the area of legal support expertise, contribute expertise to the development of training or reference materials; or in a one-on-one mentor capacity.Enter legal documents and case specific correspondence into CMS document and calendar tabs; as case progresses, independently tract and update status of attorney’s cases by obtaining due dates from the court documents or court rules and/or critical court dates and deadlines; advise attorney of upcoming commitments; deadlines and special items needing attention; using one knowledge of specific case and hearing schedules. Use Microsoft Outlook and Law Manager to monitor, update, calendar, and tickle important dates/deadlines relating to case files. Maintain f: drive case folders and hard files pursuant to established office procedures.Independently compose and prepare pleadings for trial or hearing per attorney direction, check legal citations, references and quotation information in briefs; examine documents to assure that all necessary legal steps and points have been covered, and that all legal deadlines and due process requirements are met; ensure the proper and timely filing and serving of legal pleadings in the appropriate courts and on the various parties. Independently compose letters and memoranda for attorneys.Serves as back-up to other clerical staff based on established office procedures.QualificationsOption 1: High School diploma or equivalent and four years of experience in a legal environment in support of an attorney, administrative law judge(s), review judge(s) or equivalent;Option 2: One year as a Legal Assistant 2;Option 3: A two-year degree in Legal Secretary Studies, Paralegal Studies or related field of study plus 2 years of legal office experience. A Bachelor’s degree may substitute for the Legal Secretary or Paralegal degree.**_Skills Assessment_**Applicants to the Washington State Office of the Attorney General Legal Assistant Classifications are required to take a skills assessment test, administered online by eSkill.* Applicants meeting the minimum qualifications as listed in the job announcement will receive an email from eSkill with a link to an online skills assessment. You will have three days after the email is sent to take the assessment.Supplemental Information**A background check consisting of employment history, professional references and educational verification (e.g., degree, license, or official transcript) may be conducted. Prior to any offer, the applicant selected will be required to submit to and pass a fingerprint-based criminal background check conducted by the Washington State Patrol, Criminal Records Division. The incumbent will submit to additional background checks as a condition of employment every five (5) years thereafter.****APPLICATION INSTRUCTIONS:**In addition to completing the online application, applicants must attach the following documents to their profile in order to be considered for this position:* A letter of interest, describing your specific qualifications for the position;* A current resume detailing experience and education.**READ THE FOLLOWING INFORMATION COMPLETELY:*** Carefully review your application for accuracy, spelling and grammar before submitting.* You may not reapply to this posting for 30 days.* The initial screening of applications will be solely based on the contents and completeness of the “work experience” and “education” sections of your application in www.careers.wa.gov, completeness of the application material submitted, and responses to the supplemental questionnaire.* A resume will not substitute for completing the “work experience” section of the application.* All information may be verified and documentation may be required.Honoring diversity, equity and inclusion means that as an agency, and as individuals, we are committed to ensuring that all employees and volunteers enjoy a respectful, safe and supportive working environment. Only by fostering the inclusion of people from all backgrounds, cultures and attributes, can AGO employees and volunteers achieve their fullest potential and best advance the goals and mission of the AGO.The AGO is an equal opportunity employer and does not discriminate on the basis of race, creed, color, national origin, sex, marital status, sexual orientation/gender identity, age, disability, honorably discharged veteran or military status, retaliation or the use of a trained dog guide or service animal by a person with a disability.If you are having technical difficulties creating, accessing or completing your application, please call NEOGOV toll-free at (855) 524-5627 or support@neogov.com.For assistance with the application process, please contact Judith Vandergeest at (360) 586-7691 or Judith.Vandergeest@atg.wa.gov.*Salary:* $41,352.00 – $54,108.00 Annually*Location:* Thurston County – Olympia, WA*Job Type:* Full Time – Permanent*Department:* Attorney General’s Office*Job Number:* 2021-01501*Closing:* 3/9/2021 11:59 PM Pacific*Agency:* State of Washington*Address:* View Job Posting for Agency Information View Job Posting for Location, Washington, 98504*Phone:* View Posting for Agency Contact*Website:* http://www.careers.wa.gov

 
 

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

Office: Operations

Bureau: Network Management

Working title: Medicaid Heath Systems Analyst (PN 20088913)

Job Preview:

As the Provider Enrollment Analyst, you will conduct in depth research & analysis of health care & provider eligibility requirements. Also, you will need to be well versed in Ohio Administrative Code and Federal Guidelines surrounding Provider Enrollment and Provider Enrollment related rules to be able to function as a subject matter expert. Additionally, you will attend and participate in meetings.

Job Duties:

Under direction, monitors & evaluates Medicaid providers, projects, programs (e.g., may include components) or service delivery by participation on team to: conduct in depth research & analysis of health care & provider eligibility requirements (e.g., Home & Community Based Services [HCBS] waiver) to ensure program integrity to prevent Medicaid fraud during initial enrollment & screening process; researches electronic systems & databases (e.g., Centers for Medicare & Medicaid Services [CMS] Medicare eligibility system, Provider Enrollment & Chain Ownership System [PECOS], The Information Bus Company list server [CMS TIBCO]) for other states terminated providers, System for Award Management [SAM

 
 

Clipped from: https://helponebillion.com/job/96b28460035c41d3b1d40df3b8270802/Provider-Enrollment-Analyst-Medicaid-Health-Systems-Analyst?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

 
 

 
 

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 Mgr/VA Medicaid Health Plan

**Location: This individual must live near and eventually work out of either our Richmond Health Plan office or Virginia Beach office location.

Summary: Responsible for serving as the clinical pharmacy subject matter expert for Anthem affiliated Medicaid Health Plan in VA.

Primary duties may include, but are not limited to:

+ Partners with pharmacy sales and account management to win and retain pharmacy business through clinical consultation and recommendations

+ Acts as a support resource for the sales team regarding efforts to improve the performance of the pharmacy benefit for existing accounts

+ Provides ongoing support to Anthem affiliated Medicaid Health Plan regarding pharmacy clinical programs and performance goals

+ Provides expertise and guidance regarding drug utilization, spend and trend

+ Manages both internal and external stakeholder communications for assigned area

+ Shares insights with matrix partners during the creation and roll out of new pharmacy programs

+ Ensures the proper reaction to and resolution of issues concerning the pharmacy benefit program

Qualifications

+ Requires a current unrestricted VA state license to practice pharmacy as a registered pharmacist (RPh); minimum 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

+ Minimum 2 years of pharmacy benefit management experience strongly preferred

+ Professional designation preferred

+ Excellent clinical skills, analytical ability, strategic planning, organizational, and leadership skills required

+ Proficiency in Excel, PowerPoint required

+ Strong verbal and written communication skills required

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. REQNUMBER: PS43412

 
 

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Health care and human services leaders are encouraged to consider a career opportunity with Liberty Healthcare Corporation.

An Executive Director position is now available with Liberty Healthcare which will lead a largescale healthcare quality improvement project which endeavors to enhance the health and quality of life of many people who have intellectual and developmental disabilities.

This is a client-facing and consultant-role which will lead a team of healthcare professionals working within a state human services agency.

Specific responsibilities will include:

• Quickly developing collaborative and productive relationships with various leaders and stakeholders within the client entity
• Employing a project management approach to ensuring contract deliverables met
• Leading a small and agile team of contributors / remote team
• Leveraging Medicaid / CMS expertise and best practices to guide quality improvement recommendations and initiatives
• Partnering with corporate operations leaders and resources

The end result of your work should directly translate into improved quality of life and healthcare outcomes for a significant number of people.

Please note – this is a virtual position which will allow the incumbent to work remotely from her / his home office.

Please carefully review and consider the following minimum qualifications before applying:

• Successful track record of leading large-scale health care quality improvement initiatives and projects
• At least 5 years of experience working in, partnering with, or consulting for a state government public health agency
• Deep knowledge of CMS / Medicaid services
• Master’s degree

Although not required, credentials related to project management (PMP) and/or healthcare quality (CPHQ) are highly desired. Knowledge related to the field of intellectual and developmental disabilities services is helpful.

Liberty Healthcare Corporation is a leading provider of advanced treatment delivery systems and population health management for the public and private sectors in community and facility settings. Recognized by the Centers for Medicare and Medicaid Services (CMS) as a Quality Improvement Organization – Like entity (QIO-Like entity) and Certified by The Joint Commission for our healthcare staffing program, our organization has achieved its leadership position by an unwavering commitment to our mission of providing healthcare management solutions of the highest quality that are customer-focused, cost-effective, gainful, and outcomes oriented.

Liberty Healthcare is an Equal Opportunity Employer. Diversity, equality and inclusion are among our deepest-held values.

We work to create an environment that attracts real talent and we seek to motivate, inspire and recognize high performance among all employees. regardless of race, color, religion, gender, gender identity, gender expression, sexual orientation, ancestry, national origin, age, marital or veteran status, or disability.

All qualified applicants are encouraged to apply and will receive consideration for employment.

If you are passionate about healthcare quality and seeking an opportunity to lead an impactful initiative, click “Apply” and submit your resume for immediate consideration.

 
 

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Job Location: Remote, United States, Work from home. Position Summary: This position is responsible for jointly building annual Medicare/Medicaid Pharmacy Benefits and assist with performing annual readiness claim testing (inclusive of writing and running testing scripts) with Cigna’s Medicare and Medicaid internal Pharmacy Operations teams and our Pharmacy Benefit Manager-Express Scripts (ESI).The primary focus is on Cigna – Medicare and Medicaid Pharmacy Benefit Readiness for January 1st. For 1/1/ readiness, it would include PBM (ESI) Structure and Benefit Configuration builds, benefit validations, and some testing for claim accuracy. It may also include testing for off 1/1 ESI system and Cigna Pharmacy systems scheduled releases.Throughout the year, this person will assist with ongoing Pharmacy general readiness as a response to Centers for Medicare and Medicaid Services (CMS), Office of Inspector General (OIG), Federal, State regulatory mandates.This position also plays an active role in the 1/1 Go Live – Day One Pharmacy business check outs with other internal operational teams and by performing triage and benefit research of possible claim processing issues. Primary Responsibilities :Build and maintain Pharmacy Benefit Grids for all Medicare and Medicaid Products – inclusive of both Medicare Individual and Employer product offerings.Create and maintain account structure as needed to support production expansion and complex benefit setup requirements.Coordinate structure changes with various matrix partners to ensure seamless end to end data flow between systems.Partner with IT to bridge process gaps and continuously enhance benefit automation capabilities.Perform Pharmacy Benefit Validations as assigned.Assist with providing consultations for benefit and formulary designs, benefit build process, as needed in support of any Medicare or Medicaid Pharmacy functional team (i.e. Clinical, Regulatory, Eligibility, etc.)Assist with creation and managing of the Pharmacy Benefit and Testing section of the joint Cigna-ESI Op Annual Readiness Project Plan by performing, tracking, and reporting on assigned tasksMay assist with writing and performing Medicare- Medicaid Pharmacy Benefit, Formulary and Claim processing test scripts as assignedAssist or lead facilitation of joint integrated meetings associated with pre 1/1 Readiness benefit and testing issues or post 1/1 benefit issues with Pharmacy Benefit Manager (ESI), and other internal Pharmacy functional teams such as Product, Clinical, Compliance and Government Business Operational Teams.Lead or assist with re-design and updates of documented Pharmacy benefit build and testing processes, training and job aid materials – as needed for Operational Readiness or as assigned by managerAssist various Medicare-Medicaid Pharmacy Ops Teams with performing claim tests, researching and resolving complex benefit and claim processing issues, as assigned.Compile required benefit and testing documentation for audits as needed or assigned. Qualifications :PLEASE NOTE- YOU MUST HAVE PREVIOUS HEALTHCARE OR HEALTHPLAN EXPERIENCE TO BE CONSIDEREDAssociate or Bachelor’s degree in Business, or relevant work experience in Medicare/Medicaid or Commercial Pharmacy Benefits design and Claim processing preferredPrevious Healthcare or Health Plan experience requiredIntermediate experience with Excel required 2+ years relevant experience within Pharmacy Benefits, Formulary or a Pharmacy Claim environment preferredFormulary Knowledge (Meds, Quantity Limits, Days Supply, Dosing) or Pharmacy Tech experience preferredSystem or Business Testing experience helpfulExperience with building or adhering to defined work plans and aggressive timelines – requiredExperience working with Regulatory/Compliance – Federal and State preferredHigh degree of organization and time management and productivity skills – requiredThis position is not eligible to be performed in Colorado.About CignaCigna Corporation (NYSE: CI) is a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. We offer an integrated suite of health services through Cigna, Express Scripts, and our affiliates including medical, dental, behavioral health, pharmacy, vision, supplemental benefits, and other related products. Together, with our 74,000 employees worldwide, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation.When you work with Cigna, you’ll enjoy meaningful career experiences that enrich people’s lives while working together to make the world a healthier place. What difference will you make? To see our culture in action, search #TeamCigna on Instagram.Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws. If you require reasonable accommodation in completing the online application process, please email: for support. Do not email for an update on your application or to provide your resume as you will not receive a response.

 
 

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Position:  Director Care Management – Oklahoma Medicaid
Job -1040780


Description:


BASIC FUNCTION:


This position is responsible for directing the Oklahoma Medicaid Care Management and Population Health Program. This includes supporting the design, implementation, and ongoing operations of a person-centered care model to ensure the coordination of services to address physical, behavioral, pharmacy, and social needs. The director will lead the implementation of clinical interventions; optimize the clinical review process across operations; ensure program maintains compliance with accreditation standards and government regulations; direct and develop cost of care initiatives and clinical management tools ensuring that quality, expense and performance drivers are operational; direct quality analysis, performance analysis, and customer service satisfaction standards and metrics of Clinical Operations teams; and oversee performance measures and implementing performance improvement plans to address variances.


JOB REQUIREMENTS:


* Registered Nurse (RN) with current, valid license in Oklahoma.
* 3 years clinical nursing experience.
* 5 years people management experience.
* 8 years medical management experience.
* Experience and skills in influencing, leading and directing individuals in multiple functional areas.
* Project management experience in the planning, implementation, and controlling of Medical projects.
* Knowledge of various accreditation standards, i.e., NCQA, URAC, etc.
* Knowledge of managed care principles and delivery systems.
* Familiar with claims payment rules and their impact on care management processes.
* Knowledge of healthcare/insurance industry (external market) current and future trends, to assess future market needs.
* Knowledge of Customer Service processes, workflow, systems, reporting needs, training and quality.
* Organizational skills and ability to function cooperatively to achieve organizational goals and objectives.
* Communication, leadership, team building, and quantitative analysis skills.
* PC proficiency including familiarity with various software programs i.e., Work, Excel, PowerPoint, Access, etc.


PREFERRED JOB REQUIREMENTS:


* Medicaid experience
* Certification in Case Management, Health Care Administration or Project Management.
* Knowledge or experience with quality improvement.
* Knowledge of healthcare/insurance industry, trends, regulations and future market needs.
* Knowledge of managed care service delivery processes, workflow, systems, reporting needs, training and quality.
* Collaborative leadership and teambuilding skills including influencing, leading and directing individuals in multiple functional areas.
* Clinical leadership and management experience focused in serving the children, pregnant women, chronically ill, low income and/or populations with special needs.
* Master’s degree in Nursing or other Health Sciences.


HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.


Requirements:


Expertise Network Management / Provider Relations Job Type Full-Time Regular Location OK – Oklahoma City

 
 

Clipped from: https://www.learn4good.com/jobs/oklahoma-city/oklahoma/healthcare/256541880/e/

 
 

 
 

 
 

Medicaid Actuary Data Managing Consultant

• Job Reference: 253781501-2
• Date Posted: 29 March 2021
• Company: Guidehouse
• Location: Denver, Colorado
• Salary: On Application
• Sector: I.T. & Communications
• Job Type: Permanent

Apply for this job now

Job Description

Overview Guidehouse is a leading management consulting firm serving the public and commercial markets. We guide our clients forward towards new futures that build trust in society and your professional skills along the journey. Join us at Guidehouse. Responsibilities ManagingConsultant, you will be a member of our Healthcare Public/payer practice and part of a team responsible for solving the most complex and strategic issues faced by commercial and public health, specifically in Medicaid managed care. Typically, Managing Consultants work both provide thought leadership and manage deliverables and project teams and receive exposure to a broad range of healthcare projects, including: healthcare managed care models, financial/risk modeling, and actuarial analytic support. You will be working on a variety of small project teams within the company, both receiving and providing regular mentorship from seasoned Guidehouse Consultants, as well as, work with clients allowing you access to senior client executives. Responsibilities: + Contributes to the overall content of engagement deliverables as well as the project implementation plans; leveraging his/her knowledge of: actuarial analytics (including methodologies, model development and modifications), industry reporting and research and client presentation oversight (reports, findings, exhibits and other materials). + Accountability for the execution of consulting projects to ensure timely and quality implementation of program deliverables, insuring metrics are achieved. Insure appropriate: communication, scope adjustment/documentation and client relationships are made as the project progresses. + Will help grow and develop Guidehouse’s actuarial team and solutions internally in a way that fosters career development, fiscal responsibility and culture/brand. You will have the opportunity to recruit, retain, train and guide staff to meet the needs of our project/product/documentation work and our people. + Responsible for maintaining strong client relationships, and assisting in proposal development, managing and writing responses to RFPs, account management and publications/presentations aimed at winning state actuarial program projects. + Typical project areas include (but not limited to) actuarially sound capitation rate-setting, determining and measuring managed care plan effectiveness, risk-adjustment methods, medical cost trend management, and forecasting. + Assist seasoned consultants in developing project approach, strategies, and work plans. Qualifications Required Skills + 5-8 years of successive, progressive responsibility within healthcare with a focus on healthcare actuarial consulting for public and/or commercial healthcare payers and/or providers. experience with demonstrated understanding of actuarially sound capitation rates for Medicaid programs and/or commercial payers – + Knowledge of innovative payment approaches for healthcare providers, including hospitals, physicians, nursing facilities and other long-term care providers + 5+ years with supervisory and/or project management experience managing multi-million dollar budgets. P&L management experience a plus. + Experience and credibility interacting with state officials at the executive and program levels, c-level provider and plan executives, and a strong network within the industry. + A Bachelor’s degree in computer science, mathematics, statistics, actuarial science or business administration, with an emphasis in data analysis, data grouping and large data sets + 3+ years of applicable professional experience (eg health plan or state managed care data analysis and/or healthcare consulting experience) + 3+ yrs. experience using SQL, SAS, or other third generation programming language (R, STATA, Python) that drives real value to actuarial work product. + 3+ yrs. Experience developing analytical models and structuring methodologies + Excellent quantitative analysis skills and strong data analytics background (financial modeling/planning skills a Plus) + 1+ yr. of Demonstrated management of mid-size work streams or deliverables + Proficiency with Excel, including experience in formatting, formulas, pivot tables, etc. + Ability to travel post-COVID: 10% Preferred Skills + Credentialed ASA or FSA, plus + Excellent written, verbal and presentation skills. + A strong team leader and mentor with a track record of developing mid-level and junior staff. Additional Requirements + The successful candidate must not be subject to employment restrictions from a former employer (such as a non-compete) that would prevent the candidate from performing the job responsibilities as described. + This position is open to candidate virtually from EST, CST, PST time zone as well as AZ, UT. Disclaimer About Guidehouse Guidehouse is an Equal Employment Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, citizenship status, military status, protected veteran status, religion, creed, physical or mental disability, medical condition, marital status, sex, sexual orientation, gender, gender identity or expression, age, genetic information, or any other basis protected by law, ordinance, or regulation. Guidehouse will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco. If you have visited our website for information about employment opportunities, or to apply for a position, and you require an accommodation, please contact Guidehouse Recruiting at 1-571-633-1711 or via email at (see below) All information you provide will be kept confidential and will be used only to the extent required to provide needed reasonable accommodation. Guidehouse does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of Guidehouse and Guidehouse will not be obligated to pay a placement fee. Rewards and Benefits Guidehouse offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace. Benefits include: Medical, Rx, Dental & Vision Insurance Personal and Family Sick Time & Company Paid Holidays Parental Leave and Adoption Assistance 401(k) Retirement Plan Basic Life & Supplemental Life Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts Short-Term & Long-Term Disability Tuition Reimbursement, Personal Development & Learning Opportunities Skills Development & Certifications Employee Referral Program Corporate Sponsored Events & Community Outreach Emergency Back-Up Childcare Program Position may be eligible for a discretionary variable incentive

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Senior Director of Medicaid Reimbursement-Mid Atlantic

Come Join an amazing team-amazing salary and benefits!!

The Senior Director of Medicaid Reimbursement is responsible for overseeing and management of all Medicaid Reimbursement initiatives for all case mix facilities for the company. Manage and evaluate clinical reimbursement staff in the company. Track, trend and identify arears of improvement as well as opportunities for growth. Ensure that reimbursement structures are managed, evaluated, and capture accurate resource utilization at all the facilities levels. Partner with the Clinical, Financial and therapy teams to develop and enhance clinical reimbursement tools and systems. Engage Regional RDCM, regional team, and facility teams in problems solving process to identify process opportunities for case mix index in Medicaid reimbursement.Recognizes, advises, and promotes facility best practices and systems for dealing with state Case Mix/Medicare, and Managed Care payment systems. Coordinates the MDS and Care Planning process with the facilities assigned and travels to assigned facilities as needs dictate.

Please Have The Following Qualifications

Clinical experience, education or specialty skills specific to geriatrics is desired.

Must have knowledge in PDPM assessment as well as OBRA compliance.

Demonstrates clinical assessment skills at the level necessary to meet the job requirements.

Ability to make independent decisions and follow through with limited supervision.

Knowledgeable and understanding of state and federal regulations and guidelines governing the practices of the facilities.

Effective interpersonal communication skills and the ability to work cooperatively with an interdisciplinary care team.

Able to relate positively, favorably and cooperatively with others, including, residents, family members, employee and personnel of outside agencies and organizations.

Job Requirements

Licensed Therapist or Registered Nurse

Minimum of 5 years of experience in long term care reimbursement

Multi-site Experience With Management Skills.

Excellent oral and written communication.

 
 

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Job Summary

Provide leadership and direction to assigned team members to assure that goals and standards of all areas are being met. Provides oversight of day-to-day Pharmacy Operations for the Medicaid line of business. Supports strategic initiatives to drive performance, quality, and compliance for Priority Health’s Medicaid product.

Essential Functions

* Management Responsibilities (Strategic): Contributes to the overall management strategies of the department. Responds to the needs of the department and its team members. Collaborates with other managers, supervisors and team members to solve technical and personnel issues. Clarifies direction provided by senior management. Recommends policy changes to improve department. Works closely with other supervisors and managers to assure proper alignment with long term team, department and corporate goals. Responsible for the technical and interpersonal performance of individual team members. Provides input into the development of departmental budgets.
* Management Responsibilities (Day to Day): Effectively leads the day-to-day running of Pharmacy benefits and clinical programs. Leads monitoring and auditing to ensure compliance with contracts and regulations. Develops, implement and maintain performance tracking and trending tools to allow for daily monitoring of team’s performance level for all functions. Oversees the hiring and personnel management of assigned team. Identifies training needs within team and develops appropriate action plans.
* Project Management: Provides project and program management expertise and support to capital and strategic initiatives, promotes and develops these capabilities within members of assigned teams. Participates to ensure successful delivery of a wide range of small/medium large and enterprise wide projects and programs. Effectively develop, prioritize and implement project plans as assigned by management. Communicate project goals in a clear and timely manner. Give input and sets priorities on a small, medium and large scale.

Qualifications

* Required Bachelor’s Degree or equivalent Health Care related field
* 3 years of relevant experience Leading teams in use/configuration/maintenance/testing of Pharmacy and Medical software (or comparable healthcare payer business system) Required
* Healthcare payer business system vendor management experience managing the interactions, monitoring performance of core business system application vendor in a healthcare payer setting Required

Primary Location

SITE – Priority Health – 1231 E Beltline – Grand Rapids

Department Name

PH – Pharmacy Operations

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

40

Hours of Work

8 a.m. to 4:30 p.m.

Days Worked

Monday to Friday

Weekend Frequency

N/A

Accommodation Notice: If you are a qualified individual with a disability, you may request a reasonable accommodation in Spectrum Health’s application process. Contact us at 616-486-SHHR (7447).

Spectrum Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, sexual orientation, veteran status, or any other legally protected

category. See more here.
 

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