Category: Curator- Job Hunter

CVS Health

La Place, LA Full-timeWork from home

• Help us elevate our patient care to a whole new level!
• Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models.
• You can have life-changing impact on our Dual Eligible Special Needs Plan (DSNP) members, who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges.
• With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members’ health care and social determinant needs.
• Join us in this exciting opportunity as we grow and expand DSNP to change lives in new markets across the country.
• Required Qualifications The Member Advocate works alongside other DSNP care team members including social workers, care managers and care coordinators to provide the best member experience.
• Educates and assists members on various elements of Medicaid entitlements, benefit plan information and available services created to enhance the overall member experience with the company.
• Utilizes all relevant information to effectively influence member engagement.
• Initiates contact with members who have lost Medicaid eligibility and fall into DSNP grace period to remind them to reobtain Medicaid and LIS recertification.
• Assists members with finding resources to help them reapply if necessary.
• Coordinates and sends annual reminders for members at risk of losing LIS, Medicaid, or DSNP eligibility.
• Takes ownership of each customer contact to anticipate customer needs, resolve their issues and connect them with additional services as appropriate.
• Tracks member’s Medicaid certification and eligibility dates and MCO plan information, as well as Medicaid status.
• Researches other general Medicaid programs and entitlements the members are eligible for and initiate process to inform members of these benefits.
• Completes accurate case documentation as needed.
• Works with National DSNP Program Office Medicaid Policy Manager and State Contract Manager to provide general assistance with Medicaid benefits and entitlements.
• Preferred Qualifications In-depth knowledge of benefits program and system design (Health and Welfare, Wealth, other benefits), related financials, legal/regulatory requirements.
• Knowledge and understanding of state policy or Medicaid eligibility and low-income state resources.
• Strong collaboration skills and innovative problem-solving abilities.
• Strong verbal and written communication skills.
• Ability to work independently, accurately, and e efficiently.
• Innovative Thinking and “Change Agent” Looks for, identifies and acts on opportunities to improve how we design, develop, and deliver products and services.
• Empathy towards customers’ needs and concerns.
• Education Associate’s degree or equivalent work experience.
• Business Overview At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health.
• We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused.
• Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
• We are committed to maintaining a diverse and inclusive workplace.
• CVS Health is an equal opportunity and affirmative action employer.
• We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status.
• We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

Posted 18 days agoInactive Job

Links for CVS Health

 
 

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Medicaid Transportation Advocate (54561)

Remote Opportunity To Work From Home!
Must live within a commutable distance of Syracuse, NY

HOURS: Monday – Friday 9:30am – 6:00pm or 11:30am – 8:00pm

PAY RATE: $16/hr.

CPS Recruitment is partnering with an established, 24-hour Call Center in Downtown Syracuse, NY to find 10 Medicaid Transportation Advocates to become a vital part of their growing team!

Work for a leading Medicaid transportation company that offers full-time and temp-to-hire opportunities.

If you have a positive attitude, enjoy working in a team environment and have excellent customer service skills – apply today!

Training begins 11/30/2020!

Duties & responsibilities include, but are not limited to, the following:

• Answer a high volume of inbound calls in a professional and courteous manner
• Monitor driver trips
• Override invoices
• Escalation calls
• Assist employees with questions
• Ensure full Medicaid compliance
• Assist with vendor relations and county specific tasks
• Other duties assigned by management

Minimum Qualifications:

• High School Diploma or GED
• Healthcare or Medicaid background desired
• Able to work with management
• Excellent customer service skills
• Able to handle difficult calls

Applicants must follow the CPS employment guidelines and be willing to comply with our drug screening policy and other pre-employment requirements.

How to Apply:
For consideration please submit a resume to the following:
Email: jobs@cpsrecruiter.com
Further questions, call 315-883-5507
CPS Recruitment is an Equal Opportunity Employer

CPS Recruitment is an Equal Opportunity Employer.

 
 

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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 benefits companies and a Fortune Top 50 Company.

Title: Medicaid Quality Management Health Plan Director

Location: Colorado

(The position will start out as work from home but most likely transition to the office when offices re-open)

Status: Full-time, Salary, Bonus Potential

The Medicaid Quality Management Health Plan Director is an individual contributor role that is responsible for driving the development, coordination, communication, and implementation of a strategic clinical quality management and improvement program within assigned health plan. Responsible for working with the regional head of quality management to direct the clinical quality initiatives, including HEDIS and CAHPS quality improvement, NCQA accreditation and compliance with regulatory agencies and other objectives.

Primary duties may include, but are not limited to:

+ Works with both internal and external customers to promote understanding of quality management activities and objectives within the company and to prioritize departmental projects according to Anthem corporate, regional, and departmental goals.

+ Maintains expert knowledge of current industry standards, quality improvement activities, and strong medical management skills.

+ Serves as a resource for the design and evaluation of process improvement plans/quality improvement plans and ensures they meet Continuous Quality Improvement (CQI) methodology and state contractual requirements.

+ Collaborates with other leaders in developing, monitoring, and evaluating Healthcare Effectiveness Data Information Set (HEDIS) improvement action plans, year round medical record review, and over read processes.

+ Monitors and reports quality measures per state, Centers for Medicare and Medicaid Services (CMS), and accrediting requirements.

+ No direct reports or supervisory duties

Qualifications

+ Requires BA/BS in a clinical or health care field (i.e. nursing, epidemiology, health sciences)

+ 5 years progressively responsible experience in a Healthcare- Quality Management environment for a provider or payer

+ Extensive knowledge of Medicaid

+ Any combination of education and experience, which would provide an equivalent background.

+ Live in the state of Colorado

+ MS or advanced degree in a health care related field (i.e. nursing, health education) or business strongly preferred.

+ Previous experience working with NCQA, and HEDIS preferred.

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: PS43608-US

 
 

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Management Consultant

Applicants must be willing to travel and should be within an hour of a major airport.

Company Summary

Public Knowledge is a national management consulting firm that helps government agencies solve tough problems and thrive in complex environments. We do this by providing planning, procurement, and implementation services. Most of our work is in Health and Human Services. You can learn more about us at www.pubknow.com. GLI® Group has acquired Public Knowledge, which provides Public Knowledge with the financial backing and infrastructure of a larger company.

Position Summary

This management consultant would spearhead research efforts to gather information for large projects and programs and propose creative solutions. This person would collaborate with project managers and team members to support project administration, time management, and budgeting.

Duties & Responsibilities include, but not limited to:

Research

• Gather information for a project by conducting interviews, surveys, facilitating groups, analyzing client documentation, conducting research of best practice and academic literature, and the application of other information gathering tools.

Project Support

• Learn and apply the tools and techniques we have for projects.
• Work with project managers to support the administration of projects (ensure staff adhere to standards, organizing the time of other team members, supporting project meetings, and assisting with project financial management).
• Help your team meet project objectives, timelines, and deliverables within budget.

Analysis, Communication, and Consultation

• Using your experience and research results, analyze and organize information identifying root causes of issues, opportunities for improvement, and generate ideas to improve the client situation.
• Based on your analysis, research, and experience participate with your team in the development of recommendations for actions that will improve the client situation.
• Communicate the results of our work (information, analysis, and recommendations) through the participation in the development and delivery of written reports, formal presentations, and oral discussions with your team, and as requested clients and stakeholders.

Firm Knowledge Sharing and Growth

• Freely share your knowledge, skills, and abilities with your peers in the firm.
• Perform firm administrative activities (maintain your resume, record your time accurately).
• Grow your skills and experience by participating in projects and actively pursuing continuing professional education.
• Develop an effective working relationship with clients and colleagues.

Required Education and Other Credentials:

• Bachelor’s Degree required
• Valid Driver’s License
• PMP certification is strongly preferred

Required Experience and Skills:

• At least three (3) years of project management experience, preferably in major IT systems-related work.
• At least three (3) years of experience conducting IV&V work, preferably in health or major IT systems-related work.
• Experience in systems development best practices and knowledge of the typical artifacts created as part of a system development project is required. Knowledge of Medicaid and or Integrated Eligibility is a requirement and familiarity with MITA. Knowledge of multi-project integration programs and multi-system data consolidation efforts is preferred.
• Knowledge of the components of Software Development Life Cycle and best practices including all waterfall and agile frameworks as well as SaaS, COTS, and Custom design solutions
• Deep knowledge of Medicaid and Health IT that spans the development and testing of systems through the operation of the programs the technology supports
• Proven ability to report observations, conclusions, and making recommendations for improvement about project problems and issues; ability to focus and to be objective on the assessment of SDLC processes and products
• Must have experience in bringing focus and organization to ambiguous situations
• Must demonstrate creative and strong analytical and problem-solving skills
• Demonstrates excellent interpersonal skills Must have flexibility and ability to adapt quickly to new situations
• Must have ability to establish and cultivate strong work relationships
• Must have clear, concise written and verbal communication
• Must have demonstrated life-long learning skills
• Desire to work in a collaborative, fast-paced, entrepreneurial environment
• Ability and willingness to travel (reasonable travel will be required)
• Proficient knowledge of Microsoft Word, Excel, and Outlook
• Must have excellent oral and written communication skills, including the ability to communicate with officials at all levels in government and industry
• Must have the ability to handle and organize multiple projects and deadlines
• Must demonstrate a high degree of attention to quality, details, and correctness
• Ability to work with colleagues in a virtual environment (via conference calls, web meetings, and using digital collaboration tools such as Zoom and cloud document repository)

Physical Requirements and Working Conditions:

• Must have the ability to travel to client sites
• Ability to work from a home-based office
• Must have the ability to work at a computer for extensive periods of time
• Must have the ability to speak on the telephone for extended periods of time
• Must have the ability to read (paper or computer screen) for extended periods of time
• Must have sufficient hand, arm, and finger dexterity to operate a computer keyboard and other Company equipment
• Must have the ability to be self-driven, work independently and as part of a team

We offer excellent benefits that include:

• Comprehensive Health and Dental Insurance
• Retirement Plan
• Disability Benefits
• Flexible Work Hours
• Generous Vacation Program

Applying

Think you’ve got what it takes? Apply online at on our website and include an introduction to yourself and your qualifications.

This job post should not be interpreted as all-inclusive; it is intended to identify major responsibilities and requirements of the job. The incumbent may be requested to perform other job-related task and responsibilities than those stated above.

Public Knowledge is an Equal Opportunity Employer

 
 

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JobDescription
Summary:


The Medicaid Subject Matter Expert(SME) will provide support in the area of proactive data analysis used toidentify investigative targets in the Medicaid Program. The SME will performfraud, waste and abuse detection, deterrence and prevention activitiesinvolving Medicare and Medicaid providers, suppliers, and other entitiesreceiving reimbursement under one or both of the Medicare and Medicaidprograms. This includes providers,suppliers, and other entities performing under Medicare Advantage, the MedicarePrescription Drug Program (Part D), Medicaid Managed Care, and other programsadministered or operated by CMS or State Medicaid Agencies for Medicare claimsprocessed within the jurisdiction.

Duties/Responsibilities:

· Providesubject matter expertise and technical assistance on matters related toMedicaid policies and regulations.

· Identificationof proactive data studies in the Medicaid program, resulting in identificationof high ROI fraud schemes in the Medicaid program in IL, IN, IA, KS, KY, MI, MN,MO, NE, OH and WI

· Generateinvestigative leads related to trending fraud schemes

· Remaininformed of current Medicaid fraud and abuseissues/schemes through researching reports such as CMS MIG Reviews, OIG StateReports, National Association of Medicaid Directors (NAMD) Briefs and otherresources included in the Medicaid SME Research list

· Identifyand document state program vulnerabilities

· AttendMedi-Medi meetings with external customers

· Ensureconfidentiality of all PHI and sensitive information

· Travelas required for meetings or training

· Performother duties as assigned

Minimumrequired qualifications/skills:

· BA or BS degree

· Minimum of three (3) years of Medicaidexperience is required

· Experience in program integrity or medicalreview

· Excellent oral, written and verbal skills with experiencecompiling data and writing reports

· Ability to work independently with minimalsupervision in a fast-paced environment with strict deadlines

· High proficiency level with Microsoft Excel andWord

· Working knowledge of Microsoft PowerPoint

· Excellent research skills including internetresearch

· Ability to work independently with minimalsupervision

· Must have and maintain a valid drivers licenseissued by state of residence

Preferredqualifications/skills:

· Certified Fraud Examiners (CFE) designationand/or Accredited Healthcare Fraud Investigator (AHFI) designation

SupervisoryResponsibilities:

· None

Location:

· Work from Home

OfficeEquipment (if a WFH position):

· A locking cabinet and/or desk appropriate for storingdocuments and electronic media

· A cross-cut or micro-cut (preferred) shredder

· A broadband internet connectionwith minimum download speed of 15MB – 20MB. (Wireless Air Cards are not approved forwork from home use. Free/public wi-fi connections not approved.)

· Telework office connection can be hard-wired direct orWi-Fi connection. Minimum of WPA2 (Wi-Fi Protected Access II); prefer WPA2 +AES. (WPA and WPE are not approved.) Recommended home wireless standards: WirelessG Goes through walls, but Medium speed. (Use if router not visible); WirelessN – Great for Speed, but not effective through walls. (Use if router visible); WirelessAC – High speed, but not effective through walls or distance. (Use if routervisible)

· Separate phone line (can be a cell phone)

· Office equipment (such as laptop and printerwill be provided)

PhysicalRequirements:

· May require prolonged periods of sitting at adesk.

Other:

· Successful candidates will be required to consentto background checks, credit check and other contract related screenings

· Travel may be required, and all travel expenses, if applicable,are reimbursable via GSA standards

 
 

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• Full Time
• Part Time
• Bedford,TX

 
 

**Overview** **:****This role is an opportunity to build a Data & Analytics team supporting Cigna’s Medicaid business from the ground up. The Medicaid business needs the right leader to build a mature data platform and analytics capability to enable growth. The Medicaid Data & Analytics Lead will translate the Medicaid business’s strategic objectives into a roadmap of tools and capabilities that will use data to help make better business decisions and deliver more personalized business insights. The candidate will assemble a team of data experts and business analytics professionals to deliver a broad portfolio of projects, spanning foundational data capabilities, reporting, analytical tools, population health, and customer insights. They will engage in a collaborative, cross-functional group spanning senior leadership and a variety of functional areas (e.g. operations, clinical management, finance, medical economics, and network).****The right leader will possess a strong degree of creativity, innovation, business and financial acumen, leadership ability, and a core data/analytics skillset. They will also demonstrate a talent for translating between technical and non-technical audiences, as well as a desire to champion a data-driven culture with our business partners.****Responsibilities:****Create a detailed roadmap of new capabilities and timing needed to develop a mature Medicaid analytics function** **Develop a strong perspective on the Medicaid business’s strategic goals** **Build relationships with Medicaid senior leadership and key stakeholders** **Understand the current state of Medicaid data and reporting and the existing gaps for all stakeholders** **Create a project plan to document the proposed approach to closing gaps and meeting stakeholder needs****Build a small team from the ground up to execute on the roadmap** **Lead recruitment for a talented team of data, analytics, and reporting professionals** **Set high standards for talent acquisition to attract a high-caliber team with a balance of skill-sets** **Create a team culture of success, innovation, and ethics****Create a strong data foundation for analytics, in partnership with IT organization** **Develop data views, including internal and external sources, to support automated reporting and more sophisticated analytics** **Document and work to automate existing manual data and reporting processes****Identify and recommend operational, clinical, and network trends and opportunities** **Align with state value-based programs and reporting** **Prepare population health analytics by cohorts or acuity levels** **Identify of data anomalies in network and clinical trends for action** **Support Medicaid business with proactive business analytics that align with state contracts****Lead the development of a management scorecard and a suite of reports to allow business leaders to assess and diagnose key trends** **Build automated reporting on financial performance, medical cost trend, clinical management, and other areas** **Provide insights and commentary on drivers of results****Prioritize and execute on the creation of new analytical tools to provide deeper, more granular insights on customer behavior, provider performance, clinical program outcomes, and other business drivers.** **Consider a variety of analytical techniques to meet business need (e.g. financial models, matched-case control studies, machine learning, etc.)** **Provide ad hoc analysis and insight as needed****Operate in a highly ethical and compliant manner, with attention to the unique regulatory demands of the Medicaid business****Qualifications:****Bachelor’s degree or higher in a quantitative field (statistics, mathematics, computer science, finance, actuarial science, data science, business analytics, or equivalent training)****7+ years of work experience, including experience with health care data and statistical analysis****Prior Medicaid business expertise strongly preferred, particularly with prior work in clinical, network, and/or operations functions****Strong expertise working with complex databases, including advanced SQL skills****Strong business and financial acumen, including knowledge of health insurance financial drivers****Strong customer focus, communication, and management of business partner expectations****Ability to think creatively and put structure around complex problems****Ability to translate business needs into practical applications and solutions****Ability to clearly present findings to a diverse group of teams with varying levels of technical expertise****Prior managerial experience strongly preferred****Location is flexible, including WAH option****About Cigna**Cigna 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: …@cigna.com for support. Do not email …@cigna.com for an update on your application or to provide your resume as you will not receive a response._

 
 

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Work From Home

SCHEDULE: Full-time

Do you have exceptional customer service and the ability to plan organize and exercise sound judgment? Do you have demonstrated communication, problem solving and case management skills and the ability to act/decide accordingly?

Now is the time to join our team of motivated and nurturing individuals conducting eligibility screenings, assessment of patient financial requirements, and counseling patients on insurance benefits and co-payments. The ideal Patient Support Representative serves as a liaison between the patient, hospital, and governmental agencies; and is actively involved in all areas of case management. You should also share a passion for our purpose, “To serve and enable those who care for and improve human life in their community.”

Does this sound like you? If so, APPLY TODAY. See what makes us a fabulous place to work!

Parallon is now seeking a Patient Support Representative

You can also Like us on
Facebook: https://www.facebook.com/ParallonRCSJobs.

WHAT WE CAN OFFER YOU:

• We offer you an excellent total compensation package, including competitive salary, excellent benefit package and growth opportunities. We believe deeply in our team and your ability to do excellent work with us.
• Your benefits package allows you to select the options that best meet the needs of you and your family. Benefits include 401k, paid time off, medical, dental, vision, flex spending, life, disability, tuition reimbursement, student loan repayment, employee discount program, and employee stock purchase program.

WHAT YOU WILL DO:

• Screen and evaluate patients for existing insurance coverage, federal and state assistance programs, or hospital charity application.
• Re-verifies benefits and obtains authorization and/or referral after treatment plan has been discussed, prior to initiation of treatment. Ensures appropriate signatures are obtained on all necessary forms.
• Obtain legally relevant medical evidence, physician statements and all other documentation required for eligibility determination.
• Complete and file applications. Initiate and maintain proper follow-up with the patient and government agency caseworkers to ensure timely processing and completion of all mandated applications and accompanying documentation.
• Ensure all insurance, demographic and eligibility information is obtained and entered into the system accurately. Document progress notes to the patient’s file and the hospital computer system.
• Participates in ongoing, comprehensive training programs as required.
• Follows policies and procedures to contribute to the efficiency of the office. Covers and assists with other office functions as requested.
• All other duties as assigned

ABOUT US

Parallon believes that organizations that continuously learn and improve will thrive. That’s why after more than a decade we remain dedicated to helping hospitals and hospital systems operate knowledgeably, intelligently, effectively and efficiently in the rapidly evolving healthcare marketplace, today and in the future. As one of the healthcare industry’s leading providers of business and operational services, Parallon is uniquely equipped to provide a broad spectrum of customized revenue cycle services.

Qualifications

EXPERIENCE AND EDUCATION NEEDED:

• High School Diploma or GED or related experience in lieu. College degree preferred.
• Preferred three years of hospital/medical business office experience with insurance procedures and patient interaction
• Understanding of patient confidentiality to protect the patient and the clinic/corporation.
• Ability to collect, synthesize and research complex or diverse information.

We are an equal opportunity employer and we value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.

Notice Our Company’s recruiters are here to help unlock the next possibility within your career and we take your candidate experience very seriously. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Gmail or Yahoo Mail. If you feel suspicious of a job posting or job-related email, let us know by clicking here. For questions about your job application or this site please contact HCAhrAnswers at 1-844-422-5627 option 1.

 
 

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Catapult Consultants is now hiring a Medicaid Fraud Subject Matter Expert. The expert will Develop Medicaid and Medicare-Medicaid (Medi-Medi) proactive data analysis for identification of fraud schemes and trends. Provide subject matter expertise and technical assistance on matters related to Medicaid policies and regulations.  Support the Data Analysis, Medical Review, Program Integrity and Request for Information teams by consulting with staff and participating in investigative and/or data analysis efforts. 

Key Responsibilities:

• Identification of proactive data studies in the Medicaid program, resulting in identification of high ROI fraud schemes
• Remain informed of current Medicaid fraud and abuse issues/schemes through researching reports such as CMS MIG Reviews, OIG State Reports, National Association of Medicaid Directors (NAMD) Briefs and other resources included in the Medicaid SME Research list
• Identify and document state program vulnerabilities
• Attend Medi-Medi meetings with external customers
• Ensure confidentiality of all PHI and sensitive information
• Travel as required for meetings or training
• Perform other duties as assigned

Basic Qualifications:

• High proficiency level with Microsoft Excel and Word
• Working knowledge of Microsoft PowerPoint
• Excellent verbal and written communication skills
• Excellent research skills including internet research
• Ability to work independently with minimal supervision
• Ability to perform multiple priority tasks
• Associate must have and maintain a valid driver’s license issued by his/her state of residence

Preferred Qualifications:

• A minimum of three years of Medicaid experience is required, program integrity or medical review experience preferred
• Preference given to those with experience in IL, IN, IA, KS, KY, MI, MN, MO, NE, OH, WI

Required Education:

• BA or BS degree preferred
• Preference given to candidates with Certified Fraud Examiner (CFE) and/or Accredited Healthcare Fraud Investigator (AHFI) designations

 
 

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Position:

Quality and Risk Adjustment Manager

Position Summary:

The Quality and Risk Adjustment Manager, PHSO, is the subject matter expert and lead in developing and facilitating the implementation of new and existing healthcare Quality and Risk Adjustment strategies for a PHSO client. This position advises the client on quality and risk adjustment initiatives and provides support for program planning, patient campaigns, outreach tactics, and educational programs; conducts data collection; and reports and monitors key performance measurement activities for both quality and risk adjustment.

Job Description:

Primary Responsibilities

• Manage a comprehensive and coordinated Quality and Risk Adjustment strategy for our PHSO client by: developing data mining strategies; facilitating collection methodology and an effective quality and risk adjustment program; standardizing gap closure workflows and strategies; providing support for patient campaigns, and facilitating the development and implementation of Quality and Risk Adjustment programs for internal and external PHSO clients.
  
• Develop and maintain effective internal and external relationships through effective and timely communication.
  
• Synthesize and organize data, present information, and provide executive summary of material.
  
• Take initiative and action to respond, resolve and follow up regarding quality and risk adjustment with internal and external customers in a timely manner with outstanding customer service.
  
• Develop and maintain an expert level of knowledge of PHSO Quality metrics (such as MSSP, HEDIS, MA 5-Star, NQF) and MA, ACA, and Medicaid risk-based reimbursement methodologies.
  
• Maintain professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks and participating in professional societies.
  
• Oversee and improve the various quality and risk adjustment processes.
  
• Assist client with development of a comprehensive Risk Adjustment and Quality strategy and work plan, including workflow, outcome measures and performance evaluation.
  
• Facilitate the development of key quality and risk adjustment key performance indicators.
  
• Present quality performance results and findings regularly, including the overall measure performance, improvement strategies and tactics.
  
• Serve as a quality and risk adjustment subject matter expert for internal and external clients.
  
• Support activities of the PCV (Preventative Care Visit), patient outreach, and physician educational campaigns.
  
• Perform other duties as assigned.
  

Qualifications

• Bachelor’s degree; BSN, LPN, RHIA preferred
  
• 5+ years of experience in Quality Management and experience in HEDIS, MIPS/MSSP, and MA 5-Star, preferably in a health system or clinic setting
  
• 3+ years demonstrated management and team development skills
  
• 3+ years’ experience and proven success managing, implementing and auditing clinical quality programs
  
• 3+ years’ experience within healthcare, health plan, or health system, including payer, hospitals, Medicare/Medicaid, provider environment, or managed care
  
• Knowledge of Risk Adjustment Payment methodologies; understanding of CMS HCC, HHC, and Medicaid
  
• Medicare Advantage knowledge strongly preferred
  
• Proficiency with clinical data management and statistical quality tools
  
• Analytical and quantitative problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
  
• Ability to operate in a fast-paced and dynamic environment
  
• Excellent verbal, written, and interpersonal communication skills; ability to present in front of a group
  
• Excellent organizational capabilities with ability to work effectively as a team player
  
• Strong aptitude for critical thinking and demonstrated data skills
  
• Capable of meeting deadlines and executing projects with minimal supervision
  
• Willingness to acquire new knowledge from an unfamiliar domain
  
• Ability to manage multiple job functions, priorities, and deadlines under pressure with shifting priorities in an expedient and decisive manner
  
• Ability to collaborate and work with all professional levels, internally and externally
  
• Detail oriented
  
• Proficiency in Microsoft Office Programs including Word, PowerPoint, Excel, and Outlook
  

Working Conditions

• While performing the duties of this job, the employee works in normal office working conditions.
  

Disclaimer

• The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job duties and responsibilities.
  

Lumeris is an EEO/AA employer M/F/V/D.

Location:

Remote – MO

Time Type:

Full time

 
 

From <https://lumeris.wd1.myworkdayjobs.com/en-US/LC/job/Remote—MO/Quality-and-Risk-Adjustment-Manager_R0004035?mode=job&iis=Indeed.com&iisn=Indeed.com>

*Please Note: This position is open until filled. Application assessment will be ongoing and the hiring authority reserves the right to offer the position at any time during the recruitment process. It is to the applicant’s advantage to apply as early as possible. *

 
 

The ideal candidate for this position will have program management and/or consultative experience in health services, social services or Medicaid programs. 

 
 

Position Objective:

This position participates in the design and development of programs and contracts, and the daily oversight and management of them. This includes policy promulgation, developing strategic recommendations, contract development and federal negotiations for Cost Allocation Plan (CAP) design and implementation; program and contract monitoring, developing and maintaining program guidance, developing manuals and training materials, developing and conducting program training and presentations, and providing technical assistance. This position may assist other program managers in completing these or other activities.

 
 

This position is responsible for participating in management of the Washington State Courts Juvenile Service Divisions (WSCJSD) Medicaid Administrative Claiming (MAC) program. MAC programs are a state-federal partnership which provider reimbursement to government contractors for the time they spend supporting the Medicaid State Plan. MAC programs are authorized through a federally approved CAP which describes the program and the methodology used to determine eligible reimbursements. This position supports other MAC programs in the unit, as well as reimbursement contracts with state agencies. This position may be assigned and be directly responsible for specific components of these programs.

 
 

Some of what you will do:

• Responsible for using independent judgment and program subject matter expertise and knowledge to develop, write, and oversee all aspects of assigned MAC programs and reimbursement contracts including business requirements, policy promulgation, contract and CAP development, contract execution, claiming processes, program and contract monitoring, claim payment, writing and maintaining  program manuals, training materials, and developing provider and stakeholder training to ensure the HCA’s MAC time study and claiming processes are in compliance with federal guidelines.
  
• Demonstrate extensive knowledge and understanding of applicable state and federal rules and regulations; consults with the Centers for Medicare & Medicaid Services (CMS) as required.  Utilize expert analysis of new and emerging federal and state regulations to determine the impact or need to make changes to assigned MAC programs.
  
• Provide professional and technical subject matter expertise and guidance for developing, writing, implementing, and overseeing policies and procedures having statewide impact on assigned MAC programs and reimbursement contracts.
  
• Responsible for independent judgment and program subject matter expertise to provide professional and technical expertise and guidance, consultation and recommendations for the design, development, testing and use of the numerous processes, and methods involved in the time study, claim calculations, and other aspects of MAC programs and reimbursement contracts.
  
• Designing, developing, writing, implementing, evaluating and improving monitoring tools and processes.
  
• Represent HCA and the state in negotiations with state and federal partners on major, substantive, and innovative MAC program methods and related federal law impacting HCA.
  
• Provide related MAC program and time study system training to external stakeholders, internal managers and work units as needed.
  
• Plan, design, develop, write, schedule, test, implement, evaluate and improve program policy and procedures for assigned MAC program business requirements and operational processes.
  
• Plan, design, develop, write, schedule, implement, evaluate and improve on-going training relating to program modifications needed to ensure assigned MAC programs are in compliance with federal guidelines.
  

 
 

Here is what we are looking for (Required Qualifications):

A Master’s degree with major study in public health, public administration, social work, or closely related field and two years of supervisory or consultative experience in health services, social services or Medicaid programs.

(Two additional years of qualifying experience will substitute for the required Master’s degree provided a Bachelor’s degree has been achieved)   

OR

A Bachelor’s degree and two years of experience administrating one or more statewide policies or programs of an agency or agency subdivision. 

OR

Additional qualifying experience may substitute year for year, for required education.

 
 

Desirable/Preferred Qualifications:

Communicate and work effectively with a broad range of program and fiscal managers and staff, contractors, and their agents, legislators and legislative staff, and other stakeholders.

 
 

Highly capable of working in multiple environments such as remotely and in office.

 
 

Highly capable of mastering virtual platforms and utilizing multiple different platforms on a daily basis.

 
 

Coordinate and track multiple, diverse activities and work independently with limited supervision.

 
 

Strong ability to complete assignments with limited or ambiguous guidance.

 
 

Make clear, understandable written, graphic and verbal directions.

 
 

Highly independent, self learner, with ability to easily transition between group and independent assignments.

 
 

Make presentations consisting of cost/benefit, process improvement and similar analyses and policy recommendations; capable of learning new analytics tools.

 
 

Envision and develop timely program plans and monitoring of results.

 
 

Write clear and concise reports.

 
 

About the HCA: 

The Washington State Health Care Authority (HCA) is committed to whole-person care, integrating physical health and behavioral health services for better results and healthier residents.

 
 

HCA purchases health care for more than 2.5 million Washington residents through Apple Health (Medicaid), the Public Employees Benefits Board (PEBB) Program, and the School Employees Benefits Board (SEBB) Program. As the largest health care purchaser in the state, we lead the effort to transform health care, helping ensure Washington residents have access to better health and better care at a lower cost.

 
 

What we have to offer:

• Meaningful work with friendly co-workers who care about those we serve Voices of HCA 
  
• A clear agency mission that drives our work and is person-centered HCA’s Mission, Vision & Values
  
• A healthy work/life balance, including alternative/flexible schedules and mobile work options.
  
• Infants in the workplace Infants at the Workplace Video
  
• A great total compensation and benefit package WA State Government Benefits
  
• A safe, pleasant workplace in a convenient location with restaurants, and shopping nearby. 
  
• Tuition Reimbursement
  
• And free parking! 
  

 
 

About Olympia and Washington State:

Washington State offers a total work/life package of pay, benefits, flexibility, and workplace opportunities to help you get the most out of your career and out of life. Washington State is a great place to work, play, and be a part of a community, offering quality of life that is unsurpassed. From the high energy urban center of Seattle, one of the nation’s top ranked cities, to the more relaxed pace of our rural communities, Washington’s distinctive Northwest lifestyle blends a progressive, creative culture with a casual nature.

 
 

How to Apply: 

 Only candidates who reflect the minimum qualifications on their NEOGOV profile will be considered.  Failure to follow the application instructions below may lead to disqualification.  To apply for this position you will need to complete your profile and attach:

• A cover letter that specifically addresses how you meet the qualifications for this position. 
  
• Current resume 
  
• Three professional references
  

 
 

 Washington State is an equal opportunity employer. Persons with disabilities needing assistance in the application process, or those needing this job announcement in an alternative format may call the Human Resources Office at 360.725.1761 or email Dennis.Lienemann@hca.wa.gov.

 
 

 *Prior to a new hire, a background check including criminal record history will be conducted. Information from the background check will not necessarily preclude employment but will be considered in determining the applicant’s suitability and competence to perform in the position. *

 
 

From <https://www.governmentjobs.com/careers/washington/jobs/2931459/medicaid-program-manager-maps2-mpoi>