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Clipped from: https://careers.humana.com/job/16966113/director-medicaid-strategic-solutions-remote/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Humana is at the nexus of the innovation taking place within healthcare. Broadly speaking, we are one of the most active participants in the sector. This is an exciting company headquartered in a city with an excellent quality of life!

Oliver
Director, Corporate Development and Venture Capital

 
 

I looked for the opportunity for growth and stability and I found it here.

Barry
Manager, Software Engineering Strategic HR Systems

 
 

Humana has really helped my sense of belonging because I feel part of the team.

Rosemary
Senior Consumer Experience Professional

 
 

The best part of this company is the commitment to associates, which naturally leads to commitment to members.

Abigail
Medical Director, Mid-South

 
 

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Clipped from: https://careers.guidehouse.com/veterans/jobs/21307?lang=en-us&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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Overview

 

Guidehouse is a leading global provider of consulting services to the public sector and commercial markets, with broad capabilities in management, technology, and risk consulting. By combining our public and private sector expertise, we help clients address their most complex challenges and navigate significant regulatory pressures focusing on transformational change, business resiliency, and technology-driven innovation. Across a range of advisory, consulting, outsourcing, and digital services, we create scalable, innovative solutions that help our clients outwit complexity and position them for future growth and success. The company has more than 12,000 professionals in over 50 locations globally. Guidehouse is a Veritas Capital portfolio company, led by seasoned professionals with proven and diverse expertise in traditional and emerging technologies, markets, and agenda-setting issues driving national and global economies. For more information, please visit www.guidehouse.com.

Responsibilities

 

Work with the Medicaid agency staff in reviewing the process flow of completing the quarterly CMS Medicaid/CHIP expenditure reporting forms (CMS-64, CMS-21, CMS-37, CMS-21b) and provide recommendations to make the process more efficient. Provide quality reviews and make improvements to workpapers used to prepare expenditure reporting form submissions.  Conduct training for Medicaid agency staff to address questions raised and corrections needed to the Medicaid agencies processes.  Provide technical advisory for reviews of the expenditure reporting forms performed by CMS, OIG and state auditors.  Reconcile expenditure reporting forms to state accounting and claim records. 

 
 

 
 

Job Description/Responsibilities: (bullet format)

• Assess weakness and provide recommendations on reporting of expenditures, audit adjustments, recoveries, overpayments on the CMS-64, CMS-21, CMS-37, and CMS-21b.
  
• Support and audit each step in accumulating, confirming, adjusting, and allocating data as the CMS-64 and CMS-21 reports are completed.
  
• Develop reconciliation processes to map expenditures and revenue from the state accounting and claim systems to entries made into the Medicaid and Children’s Health Insurance Program Budget and Expenditure System (MBES).
  
• Review workbooks used to support the CMS-64 and CMS-21. Ensure workpapers prepared by Medicaid agency staff have been compared to entries made into MBES.  Ensure that any noted variances noted are resolved and that all entries are properly reported prior to certification of the CMS-64 and CMS-21.
  
• Prior to the end of the federal fiscal year, prepare the following reconciliations of CMS-64 and CMS-21:
  

 
 

• Reconcile Federal draws from the U.S. Treasury Payment Management System (PMS) to the Federal Share reported on the CMS-64 and CMS-21.
  
• Reconcile Non-Federal share to the total State General Revenue and other revenue sources maintained in a state agencies fund accounting system.
  
• Prepare work plans with tasks and target dates for developing protocols, procedures and supporting work templates for the federal reporting forms.
  
• Provide status updates to Medicaid agency staff on the progress made in completing work plan tasks.
  
• Develop and deliver technical training to Medicaid agency staff on CMS-64, CMS-21, CMS-37, and CMS-21B requirements and processes.
  
• Provide technical advisory on reviews and audits of the CMS-64, CMS-21, CMS-37, and CMS-21B performed by external reviewers.
  
• Support various program integrity and audit projects.
  

 
 

 
 

Qualifications

 

• BA/BS degree in Health Policy, Economics, Finance, Data Science or other Healthcare/Science/Finance related disciplines OR 10yrs. similar relevant experience, Master’s degree preferred
  
• 7+ years of experience working with Medicaid/Medicare or other health care claims data. 
  
• 5+ years of previous work experience in the health care industry or with a consulting firm to include the following:
  

 
 

• A complete understanding of the flow information through the forms reported on CMS-64, CMS-21, CMS-37, and CMS-21B reports.
  
• Knowledge of all code of federal regulations (CFR’s), state Medicaid manual references, state Medicaid director’s letters, departmental appeals board (DAB) decisions, Office of Management and Budget (OMB) circulars and title XIX/title XXI of the social security act citations applicable to Medicaid and CHIP expenditure federal reporting.
  
• Familiarity with Medicaid State Plan Amendments and Public Assistance Cost Allocation Plans.
  
• Understanding of basic Medicaid reimbursement methodologies including per diems, Diagnosis Related Group (DRG), Ambulatory Payment Classifications (APC’s), Resource-based relative value scale (RBRVS), Resource Utilization Groups (RUG) and Medicare cost reporting principles.
  
• Ability to work overtime
  

 
 

Preferred:

 
 

• 7+years of experience working on hospital-based financing for Medicaid payments (IGT, CPE, CMS-64, DSH assessments, etc.)
  
• 5+ years of experience working in a variety of State Medicaid Programs (Rate Setting, CMS 64 other payment initiatives)
  
• 5+ years of experience preparing deliverables for healthcare payment and pricing projects, payment incentive models, hospital payment adequacy analyses, federal compliance for Medicaid programs, and federal revenue enhancement programs
  
• 5+ years of experience using the CMS-2552-10, Medicare acuity, and Medicaid quality scores in assessing hospital performance and hospital reimbursement through Medicaid
  

 
 

• Knowledge and experience with the application of methods for risk adjustment, reserving, pricing, and forecasting for health insurance
  
• Ability to engage in relationship initiation and cultivation with state Medicaid leaders and/or hospital industry leaders.
  
• Proficient in Microsoft Office Suite 
  

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 esponsibilities as described.
  
• The salary range for this consultant role is $140,000 to $200,000 but may vary based on experience and location
  
• Applicants must be currently authorized to work in the United States for any employer.
  
• No sponsorship is available for this position.
  

 
 

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 RecruitingAccommodation@guidehouse.com. 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
  
• Position may be eligible for a discretionary variable incentive bonus
  
• 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
  

#LI-Remote

Clipped from: https://www.learn4good.com/jobs/atlanta/georgia/management_and_managerial/1682279245/e/

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What job do you want?

Maximus seeks an implementation director with Medicaid experience overseeing the implementation and integration of government systems and operational projects. The ideal candidate has experience in transformation projects, replacing legacy systems with modular, integrated systems and a background in Medicaid or healthcare systems. However, other system transformation and integration experience will be considered.

Primary Responsibilities:

 

• Manage Maximus departments, in a matrix environment, to successfully implement new contracts
  
• Create and maintain project schedules
  
• Present status reports to internal and external clients
  
• Write and review project deliverables
  
• Lead requirements gathering and analysis sessions
  
• Manage all client contact throughout the implementation of a complex project, including systems and operations projects
  
• Track all implementation activities and artifacts. Lead and participate in requirement and process analysis sessions and interviews
  
• Create MS Project schedules to align with required timeline and scope
  
• Create and review project deliverables
  
• Maintain project forecasts and budgets
  
• Collaborate with various functional and technical teams (Maximus and external partners) to ensure timeline, complete, and accurate implementations
  
• Contribute to corporate repository of project standards
  
• Contribute to proposal writing
  
• Bachelor’s degree from an accredited college or university in Business, Management Information Systems, Computer Science, Public Administration, or a related field
  
• 7 years of relevant professional experience
  
• At least 7 years of project management experience which must include leadership of at least one complex project
  
• PMP certification required
  
• Must possess exceptional organizational, interpersonal, written and verbal communication skills
  
• Must be able to communicate effectively and professionally, verbally and in writing, to all segments of the population
  
• Experience in managing both staff and processes, deadline-oriented work, budgets and revenue and profitability
  
• Experience leading complex projects spanning multiple knowledge, technical, and functional disciplines
  
• Health or Human Services experience a plus
  
• Experience working as a team member and independently
  
• Strong computer skills, including intermediate to expert skill level of MS Office, MS Project, and Share Point
  
• Travel may be required to project sites during implementations
  
• Knowledge of Medicaid Management Information Systems (MMIS) or Medicaid Enterprise Systems (MES)
  
• Experience working on Medicaid modernization projects
  
• Manage the implementation of MMIS onents or modules
  
• Experience integrating complex system platforms across providers, members, and health plans
  

Recommended Skills
 

• Best Practices
  
• Business Process Improvement
  
• Health And Human Services
  
• Metrics
  
• Project Management
  

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Clipped from: https://www.ziprecruiter.com/c/Horizon-Blue-Cross-Blue-Shield-of-New-Jersey/Job/Mgr,-Medicare-&-Medicaid/-in-Pennington,NJ?jid=626ce7ea19076234&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:
The Manager, Medicare and Medicaid Risk Adjustment is responsible to act as the lead for multiple data projects and tasks working directly with the Director, Risk Adjustment Revenue. This position will be actively involved in managing the company’s Medicare and Medicaid risk adjustment revenue management and analysis. This position will work interdepartmentally as well as with outside vendors, such as, but not limited to, Inovalon, Cognizant, Cognisight, Apixio, Change Healthcare, Pharmacy Benefit Administrator (PBA), Membership Systems, etc., in matters related to the membership, revenue, risk adjustment accuracy, and data submission completeness & accuracy. Lead an analytics-focused team and manage a coordinated, cross-functional and integrated process across the organization with partners in Service, Informatics, HCM&T, and IT to implement the programs and streamline and leverage activities.

• Manage the existing Medicare risk adjustment programs, ensuring risk score accuracy capabilities, timely and accurate data submissions, financial impact and related functions. Responsible for managing the Medicare Risk Adjustment Processing System (RAPS) and Encounter Data Processing (EDPS) Submission process and reconciliation of submissions against claims data. Coordinate the work of government audit on risk adjustment data (RADV Audit). Assist in implementation and management of Risk Adjustment related vendor activities.
  
• Oversee DSNP vendor relationships, establishing clear performance goals and expectations. Coordinate the operations for vendors in developing data extracts for accurate and timely RAPS/EDPS submissions as it relates to chart review and in-home assessments. Track vendor progress in meeting deadlines, reporting accurate and complete data.
  
• Establish appropriate receivable balances and the application of monthly payment remittances from the Centers for Medicare and Medicaid Services (CMS) and New Jersey State Department of Human Services Division of Medical Assistance and Health Services (DMAHS).
  
• Manages the DSNP NJ State/CMS reconciliation of preparation and distribution of monthly premium and enrollment derived from the Monthly Membership Report (MRR) and Remittance Advice (RA) respectively.
  
• Prepare and analyze financial data and reports and for maintenance and reconciliation of receivable balances and accounts. Implement and monitor basic control processes, communications improvements, and analysis.
  
• Oversee Medicaid Pharmacy Benefit Administrator (PBA) ensuring timely and accurate Encounters submissions & reconciliation aligning with the TR65 certification. Coordinate cross-functional meetings with various functional areas to meet overall stakeholder expectations and plan’s objectives.
  
• Manage data assurance and reconciliation of Medicare Prescription Drug Event (PDE) data interdepartmentally.
  
• Responsible for duties including training, development, communication and implementation of office audit standards, policies and procedures, reviewing monitoring, establishing tasks, setting goals and evaluating of employee work performance, reviewing operational programs, establishing work priorities, and researching technical and procedural issues related, but not limited to the actions that could potentially affect the member premium. Work in partnership with customers, vendors, and other key stakeholders to deliver the service and products required. Create/revise policies and procedures in accordance with the State and federal requirements and maintain compliance.
  
• Manage, develop and train four – six staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.
  

Education/Experience:
 

• Bachelor degree preferred from an accredited college or equivalent work experience
  
• Requires a minimum of five to eight years of experience in Accounting, Revenue and/or Healthcare Accounts Receivable Management, preferably for a payer organization
  
• Requires premium and/or healthcare receivable management experience (claims processing experience is preferred).
  
• Requires experience processing and analyzing large data files including directing the development of queries and reports to support the management of accounts receivable balances.
  
• Experience in the Medicare and/or Medicaid Managed Care industry is preferred.
  

Knowledge:
 

• Requires working knowledge of personal computers and supporting windows based environment including MS Access, Excel, and Word.-Requires knowledge of claims processing.
  
• Prefers knowledge of industry standard claims coding.
  
• Requires knowledge of provider contracting.
  
• Prefers knowledge of claim system configurations.
  
• Prefers project management skills.
  
• Knowledge of CMS Risk Adjustment Process (RAPS), State and Federal Encounters-Reporting, Part D, Premium Billing, Membership Reconciliation, CMS and State of NJ Revenue Cycle desired.
  

Skills and Abilities:
 

• Requires analytical and problem solving skills.
  
• Requires strong oral and written communication skills.
  
• Requires the ability to adapt to change and meet deliverables in a fast paced, dynamic environment.
  
• Requires the ability to research and resolve problems through interaction with companywide personnel.
  
• Requires the ability to organize and prioritize work assignments.
  
• Requires effective verbal and written communication skills and demonstrate the ability to work well within team.-Requires the ability to work independently and coordinate projects.
  

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

Clipped from: https://careers.novonordisk.com/job/Plainsboro-Senior-Associate-Government-Contracts-Medicaid-NJ/855776001/?feedId=300501&utm_source=HireLifeScience&utm_campaign=NovoNordisk_HLS

About the Department                                                                                                                                                 

At Novo Nordisk, our Strategy, Finance, and Operations team works to provide strategic direction to the company, ensuring that everything we do is viable and built to last. Overseeing and safeguarding Novo Nordisk’s short and long-term planning, the Strategy, Finance and Operations team works closely with the business across the organization to develop strategies and business plans, monitor industry trends, and provide operating recommendations. We regulate accounting, uphold workplace safety, manage our supply chain and sampling, support technology, provide commercial insights & analytics, maintain our facilities and assure the integrity and completeness of all business transactions. At Novo Nordisk, you will have the opportunity to build a life-changing career in a global business environment. We encourage our employees to make the most of their talent. And we reward hard work and dedication with the opportunity for continuous learning and personal development. Are you ready to realize your potential?

 
 

The Position

Responsible for processing and reconciling the Medicaid rebate claims utilizing the Model N Medicaid System. Regularly coordinates with State Medicaid agencies, contract administrators and assists with analyses on resolutions. Ensures Novo Nordisk Inc (NNI) compliance with the Medicaid Drug Rebate Program (MDRP).

 
 

Relationships

Reports to an Associate Director manager in Government Contracts – Medicaid. Internal relationships include Government Contracts, Pricing, Pricing, Contract Operations & Reimbursement and general finance. External relationships include Centers for Medicaid and Medicare Services (CMS), State Medicaid agencies and Pharmacy Benefit Administrators.

 
 

Essential Functions

• Data Analysis and Medicaid Reporting
  

 
 

• Attends Financial Planning &Analysis (FP&A) forecasting meetings and provides guidance to FP&A Department on potential future Medicaid events that could impact rebate forecasting
  
• Analyzes and ensures accuracy of state rebate formatted data for each level of processing
  
• Assists management in Government Compliance regarding pricing and reporting issues as required
  
• Prepares and provides standard Medicaid rebate reports to field and home office management. These reports include state utilization trending, claim receipt status, reconciliation of state invoice and ad-hoc reporting
  
• Prepares Medicaid data analyses to explain variances between rebate periods
  
• Reviews and analyzes contract terms and conditions; ensures data in the Model N Medicaid system reflects the current contract terms for accurate processing
  
• Medicaid Rebates
  

 
 

• Acts as company liaison, negotiating with state Medicaid agencies and Pharmacy Benefit Administrators regarding dispute resolution with a third party Consultant
  
• Assists internal & external customers with inquiries relating to Medicaid payments, dispute and contracts
  
• Builds and maintains relationships with internal stakeholders to build an understanding of business objectives
  
• Coordinates Medicaid claim data entry with third party vendor
  
• Coordinates Medicaid disputes with third party dispute vendor and provides periodic reporting to Senior Management.
  
• Develops and distributes quarterly analysis of Medicaid Rebate Liability
  
• Ensures compliance with all state mandated due dates by avoiding interest penalties at all times
  
• Ensures that all dispute inquires and claim level details received from the States are submitted to dispute resolution consultant in a timely manner
  
• Maintains knowledge in operation of Model N Medicaid Rebate Processing system
  
• Prepares/reviews quarterly Federal Medicaid, ADAP, SPAP (State Programs), and Supplemental Invoices; prepares/reviews prior quarter adjustments as necessary
  
• Responsible for the timely and accurate payments of all Federal and State Medicaid Rebate claims
  
• Reviews state utilization data for reasonableness and quantifies and accounts for Medicaid dispute exposure
  
• Serves as point of contact for all State Medicaid customers regarding rebate payment inquiries
  
• Stays up-to-date and applies knowledge of the Medicaid Rebate legislation to all Federal and individual State programs
  

 
 

• Systems Maintenance/Contract Administration
  

 
 

• Assists internal and external customers with inquiries relating to Medicaid payments, dispute resolution and contract inquiries
  
• Coordinates the implementation of Medicaid system enhancements and testing
  
• Coordinates with Accounts Payable and IT regarding SAP interface check requests and wire transfers
  
• Formats incoming claims data from Medicaid contract customers; ensures rebate claims data is in proper format
  
• Maintains up-to-date knowledge of Model N Medicaid system and coordinates with IT and Model N tech support as necessary
  
• Processes, reviews and validates all Medicaid rebate claims, ensuring all payments are made within the required timeframes, as stated in the contractual agreements
  
• Utilizes DNA Software for State Preferred Drug Lists and dispute analysis
  

 
 

Qualifications

• A Bachelor’s degree required; relevant experience may be substituted for degree when appropriate
  
• 3 years relevant experience preferred with at least 1 year required
  
• Ability to interact with various departments and levels internally and externally
  
• Ability to work independently
  
• Advanced PC skills required
  
• Experience with Government Pricing Medicaid rebate system preferred (Model N)
  
• Intermediate skills in Access and Showcase Query preferred
  
• Intermediate skills in Microsoft Excel required
  
• Knowledge of Medicaid Drug Rebate Program desirable
  
• Strong analytical, quantitative, and qualitative analysis skills required
  
• Strong attention to detail required
  
• Strong organization and prioritization skills required
  

 
 

We commit to an inclusive recruitment process and equality of opportunity for all our job applicants.

 
 

At Novo Nordisk we recognize that it is no longer good enough to aspire to be the best company in the world. We need to aspire to be the best company for the world and we know that this is only possible with talented employees with diverse perspectives, backgrounds and cultures. We are therefore committed to creating an inclusive culture that celebrates the diversity of our employees, the patients we serve and communities we operate in. Together, we’re life changing.

 
 

Novo Nordisk is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, ethnicity, color, religion, sex, gender identity, sexual orientation, national origin, disability, protected veteran status or any other characteristic protected by local, state or federal laws, rules or regulations.

 
 

Novo Nordisk requires all new hires to be fully vaccinated against COVID-19 prior to the first date of employment. As required by applicable law, Novo Nordisk will consider requests for reasonable accommodation.

 
 

If you are interested in applying to Novo Nordisk and need special assistance or an accommodation to apply, please call us at 1-855-411-5290. This contact is for accommodation requests only and cannot be used to inquire about the status of applications.

Clipped from: https://hirelifescience.com/career/117892/Senior-Associate-Government-Contracts-Medicaid-New-Jersey-Nj-Plainsboro

About the Department

At Novo Nordisk, our Strategy, Finance, and Operations team works to provide strategic direction to the company, ensuring that everything we do is viable and built to last. Overseeing and safeguarding Novo Nordisk’s short and long-term planning, the Strategy, Finance and Operations team works closely with the business across the organization to develop strategies and business plans, monitor industry trends, and provide operating recommendations. We regulate accounting, uphold workplace safety, manage our supply chain and sampling, support technology, provide commercial insights & analytics, maintain our facilities and assure the integrity and completeness of all business transactions. At Novo Nordisk, you will have the opportunity to build a life-changing career in a global business environment. We encourage our employees to make the most of their talent. And we reward hard work and dedication with the opportunity for continuous learning and personal development. Are you ready to realize your potential?

The Position


Responsible for processing and reconciling the Medicaid rebate claims utilizing the Model N Medicaid System. Regularly coordinates with State Medicaid agencies, contract administrators and assists with analyses on resolutions. Ensures Novo Nordisk Inc (NNI) compliance with the Medicaid Drug Rebate Program (MDRP).

Relationships

Reports to an Associate Director manager in Government Contracts – Medicaid. Internal relationships include Government Contracts, Pricing, Pricing, Contract Operations & Reimbursement and general finance. External relationships include Centers for Medicaid and Medicare Services (CMS), State Medicaid agencies and Pharmacy Benefit Administrators.

Essential Functions
 

• Data Analysis and Medicaid Reporting
  

 
 

• Attends Financial Planning &Analysis (FP&A) forecasting meetings and provides guidance to FP&A Department on potential future Medicaid events that could impact rebate forecasting
  
• Analyzes and ensures accuracy of state rebate formatted data for each level of processing
  
• Assists management in Government Compliance regarding pricing and reporting issues as required
  
• Prepares and provides standard Medicaid rebate reports to field and home office management. These reports include state utilization trending, claim receipt status, reconciliation of state invoice and ad-hoc reporting
  
• Prepares Medicaid data analyses to explain variances between rebate periods
  
• Reviews and analyzes contract terms and conditions; ensures data in the Model N Medicaid system reflects the current contract terms for accurate processing
  
• Medicaid Rebates
  

 
 

• Acts as company liaison, negotiating with state Medicaid agencies and Pharmacy Benefit Administrators regarding dispute resolution with a third party Consultant
  
• Assists internal & external customers with inquiries relating to Medicaid payments, dispute and contracts
  
• Builds and maintains relationships with internal stakeholders to build an understanding of business objectives
  
• Coordinates Medicaid claim data entry with third party vendor
  
• Coordinates Medicaid disputes with third party dispute vendor and provides periodic reporting to Senior Management.
  
• Develops and distributes quarterly analysis of Medicaid Rebate Liability
  
• Ensures compliance with all state mandated due dates by avoiding interest penalties at all times
  
• Ensures that all dispute inquires and claim level details received from the States are submitted to dispute resolution consultant in a timely manner
  
• Maintains knowledge in operation of Model N Medicaid Rebate Processing system
  
• Prepares/reviews quarterly Federal Medicaid, ADAP, SPAP (State Programs), and Supplemental Invoices; prepares/reviews prior quarter adjustments as necessary
  
• Responsible for the timely and accurate payments of all Federal and State Medicaid Rebate claims
  
• Reviews state utilization data for reasonableness and quantifies and accounts for Medicaid dispute exposure
  
• Serves as point of contact for all State Medicaid customers regarding rebate payment inquiries
  
• Stays up-to-date and applies knowledge of the Medicaid Rebate legislation to all Federal and individual State programs
  

 
 

• Systems Maintenance/Contract Administration
  

 
 

• Assists internal and external customers with inquiries relating to Medicaid payments, dispute resolution and contract inquiries
  
• Coordinates the implementation of Medicaid system enhancements and testing
  
• Coordinates with Accounts Payable and IT regarding SAP interface check requests and wire transfers
  
• Formats incoming claims data from Medicaid contract customers; ensures rebate claims data is in proper format
  
• Maintains up-to-date knowledge of Model N Medicaid system and coordinates with IT and Model N tech support as necessary
  
• Processes, reviews and validates all Medicaid rebate claims, ensuring all payments are made within the required timeframes, as stated in the contractual agreements
  
• Utilizes DNA Software for State Preferred Drug Lists and dispute analysis
  

Qualifications

 

• A Bachelor’s degree required; relevant experience may be substituted for degree when appropriate
  
• 3 years relevant experience preferred with at least 1 year required
  
• Ability to interact with various departments and levels internally and externally
  
• Ability to work independently
  
• Advanced PC skills required
  
• Experience with Government Pricing Medicaid rebate system preferred (Model N)
  
• Intermediate skills in Access and Showcase Query preferred
  
• Intermediate skills in Microsoft Excel required
  
• Knowledge of Medicaid Drug Rebate Program desirable
  
• Strong analytical, quantitative, and qualitative analysis skills required
  
• Strong attention to detail required
  
• Strong organization and prioritization skills required
  

We commit to an inclusive recruitment process and equality of opportunity for all our job applicants.

At Novo Nordisk we recognize that it is no longer good enough to aspire to be the best company in the world. We need to aspire to be the best company for the world and we know that this is only possible with talented employees with diverse perspectives, backgrounds and cultures. We are therefore committed to creating an inclusive culture that celebrates the diversity of our employees, the patients we serve and communities we operate in. Together, we’re life changing.

Novo Nordisk is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, ethnicity, color, religion, sex, gender identity, sexual orientation, national origin, disability, protected veteran status or any other characteristic protected by local, state or federal laws, rules or regulations.

Novo Nordisk requires all new hires to be fully vaccinated against COVID-19 prior to the first date of employment. As required by applicable law, Novo Nordisk will consider requests for reasonable accommodation.

If you are interested in applying to Novo Nordisk and need special assistance or an accommodation to apply, please call us at 1-855-411-5290. This contact is for accommodation requests only and cannot be used to inquire about the status of applications.

Clipped from: https://www.themuse.com/jobs/cvshealth/lead-director-network-provider-relations-michiganmedicaidremote-41027a?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Job Description
The Michigan Medicaid Network State Director manages and oversees compliance with our Network responsibilities as provided within the State Medicaid contractual requirements as outlined below:

• This Position will manage separate functions for external provider engagement representatives and internal provider relations representatives to ensure successful Provider Relationships, Network Performance including Clinical and Affordability Targeted Improvements as identified.
• The State Network Director will manage and deploy the Medicaid National Provider Engagement Program through the Local Market Network Engagement Provider Representatives within their respective Leadership
• The State Network Director will manage and direct the internal / external Network Provider Relations staff to ensure “best in class” Provider Relationships
• The State Network Director will assist in the recruitment of new providers as needed and maintain compliance with all network access requirements.
• Develops and implements training programs and educational materials for providers as well as for internal staff and aligns Network functions with Operations and Claims as needed.
• Assist and develop Network Action Plans to ensure Network Compliance with any and/all State Network Compliance requirements

Role/responsibilities
• Manages Local Provider Engagement Team to Deploy National Engagement Model
• Manages Local Provider Relations staff to ensure Market Leading Provider Satisfaction
• Provides direction to operations teams regarding policy and procedures related to claims/providers.
• Facilitates Provider Advisory Group and JOC meetings to work with management to implement changes via coordination with Quality Management to develop appropriate provider Clinical measure improvements and implement those measures in the provider community.
• Oversees the monitoring of executed provider contracts to ensure Network Access meets State requirements.
• Coordinate’s provider information with Member Services and other internal departments as requested.
• Provides service to providers by resolving problems and advising providers of new protocols, policies, and procedures.
• Develops training materials for staff and provider network; oversees staff responsible for initial and ongoing provider in-services and provider education; develops and implements provider satisfaction surveys.
• Participates in Grievance and Appeals meetings, tracks and trends provider grievances, monitors staff for timely compliance;
• Compiles data and staff metrics in order to complete regulatory deliverables; participates in all internal compliance audits and Regulatory reviews.
• Researches, reviews, and prepares response for all governmental, regulatory and quality assurance provider complaints ; timely and continuous reconciliation of provider records; oversees Provider Access and Availability by reviewing Appointment Availability Audits conducted by staff.
• Provides support and maintenance assistance for websites, portals, directories, manuals, and dashboards; plans, coordinates, and conducts provider forums and monthly webinars; develops communications including newsletters, notifications and Fax Blasts.
• Provides assistance and support to other departments, as needed, to obtain crucial or required information from Providers, such as HEDIS, Credentialing, Grievance and Appeals, SIU, etc. Coordinates provider status information with Member Services and other internal departments.
• Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including, employment, termination, performance reviews, salary reviews, and disciplinary actions. Monitors staff performance, including weekly staff metrics; coaches and mentors’ staff on performance issues or concerns.
• Promotes and educates providers on cultural competency

Pay Range
The typical pay range for this role is:
Minimum: 100,000
Maximum: 221,000

Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.

Required Qualifications
• Minimum of 5 to 7 years recent Managed Care Network experience in Provider Relations & Employee Supervision with 3-5 Years Medicaid Network
• Excellent interpersonal skills and the ability to work with others at all levels
• Knowledge of Medicaid Regulatory Standards for Network Access, Credentialing, Claims Processing, Provider Appeals & Disputes and Network Performance Standards
• Excellent analytical and problem-solving skills
• Strong communication, negotiation, and presentation skills
• Knowledge of Michigan Medicaid.

Preferred Qualifications
Master’s degree preferred.

Candidates to reside in applicable State or surrounding State.

Education
• Bachelor’s degree in a closely-related field or an equivalent combination of formal education and recent, related experience.

Business Overview
Bring your heart to CVS Health
Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand – with heart at its center – our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.
We strive to promote and sustain a culture of diversity, inclusion and belonging every day.
CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Clipped from: https://simplify.jobs/p/78327025-86c0-42a4-a354-13c73bb5bd9b/Community-Health-Care-Case-Worker?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Outreach Specialist

Posted on 11/1/2022

Locations

Toledo, OH, USA

Experience Level

Entry

Junior

Mid

Senior

Expert

Desired Skills

Customer Service

Requirements

• Requires HS Diploma and a minimum of 1 year of customer service experience, or any combination of education and experience that would provide an equivalent background
  
• For Medicaid business units, a Community Health Worker Certification is required
  

Responsibilities

• Responds to telephone, written, and in-person inquiries and initiates steps to assist regarding issues relating to content or interpretation of benefits, policies and procedures
  
• Provides timely and accurate resolution of inquiries and issues regarding benefits, services and policies
  
• Supports and promotes State Sponsored Programs through participation in community events
  
• Represents State Sponsored Programs in community collaborations
  
• Supports member access to care through home visits, processing of reports, and distribution of collateral materials
  
• Performs new member orientations
  
• Provides superior quality outcomes by taking ownership of issues to ensure timely resolution or follow-up
  
• Provides superior, professional, and courteous service to customers. Comprehends the various cultural and linguistic needs of the Medicaid and SCHIP population, knowledge of the various health and social services available in the assigned region with a special emphasis on services offered by community based organizations, ability to work professionally with the company’s associates, community-based organizations, providers and plan members
  

Desired Qualifications

• Understanding of the basic principles of managed care and the concepts of publicly financed health insurance such as Medicaid and SCHIP programs is preferred
  

Position Title:

Community Health Care Case Worker (Outreach Specialist)

Job Description:

Responsible for serving as the initial and main point of Field contact between the Company and current and potential members.

Primary duties may include, but are not limited to:

• Responds to telephone, written, and in-person inquiries and initiates steps to assist regarding issues relating to content or interpretation of benefits, policies and procedures.
  
• Provides timely and accurate resolution of inquiries and issues regarding benefits, services and policies.
  
• Supports and promotes State Sponsored Programs through participation in community events.
  
• Represents State Sponsored Programs in community collaborations.
  
• Supports member access to care through home visits, processing of reports, and distribution of collateral materials.
  
• Performs new member orientations.
  
• Provides superior quality outcomes by taking ownership of issues to ensure timely resolution or follow-up.
  
• Provides superior, professional, and courteous service to customers. Comprehends the various cultural and linguistic needs of the Medicaid and SCHIP population, knowledge of the various health and social services available in the assigned region with a special emphasis on services offered by community based organizations, ability to work professionally with the company’s associates, community-based organizations, providers and plan members.
  

Minimum Requirements: 

•  Requires HS Diploma and a minimum of 1 year of customer service experience, or any combination of education and experience that would provide an equivalent background.
  
• For Medicaid business units, a Community Health Worker Certification is required.
  

Preferred Skills, Capabilities and Experiences: 

•  Understanding of the basic principles of managed care and the concepts of publicly financed health insurance such as Medicaid and SCHIP programs is preferred.  
  

Job Level:

Non-Management Non-Exempt

Workshift:

Job Family:

CUS > Care Reps

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.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealth.com. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contactability@icareerhelp.comfor assistance.

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.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at
careers.ElevanceHealth.com. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ability@icareerhelp.com for assistance.

Clipped from: https://www.mendeley.com/careers/job/senior-data-analyst-17823820?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

**Type of Requisition:** Regular

**Clearance Level Must Be Able to Obtain:** None

**Job Family:** Data Analysis

GDIT is searching for Senior Data Analyst to join our growing team. You will support an exciting new program focused on identifying vulnerabilities in Medicaid, Medicare and the Marketplace. The position will focus on reviewing and analyzing publicly available data related to Medicaid, Medicare, and/or Marketplace exchanges. Our work depends on a Senior Data Analyst joining our team to support our customer, Center for Medicare and Medicaid Services (CMS) activities. At GDIT, our people are at the center of everything we do. As a Senior Data Analyst supporting CMS Vulnerability Management Contract. You will be trusted to work on specific technology and data science tools to identify vulnerabilities within CMS’ programs in Medicare, Medicaid, and Marketplace. In this role, a typical day will include:

+ Collaborating with CMS Center for Program Integrity (CPI) to effectively identify and target specific healthcare vulnerabilities to detect and prevent FWA

+ Extract qualitative and quantitative relationships (i.e., patterns, trends) from large amounts of publicly available data using SAS, SQL, R, Python, or other statistical tools

+ Gather and organize information for use in supporting decision-making process

+ Collect, manipulate, analyze, evaluate, and display data using visualization tools

+ Perform data analysis and create data summaries using descriptive statistics

+ Implement open-ended data merges, data analysis plans, and perform complex data manipulation and reporting tasks

+ Develop, write, and present detailed technical solutions to solve open-ended business problems to technical and non-technical audiences

**Required Skills:**

+ Bachelor’s degree and 8+ years related experience (or equivalent combination of education and experience such as a Masters and 6+ or no degree and 12 years)

+ Medicare, Medicaid and/or Healthcare Marketplace experience

+ Superior skills conducting statistical and mathematical modeling and analysis using SAS software

+ Superior skills using SQL for data manipulation purposes

+ Experience developing and presenting solutions to complex, open-ended problems

+ Experience proactively identifying and working collaboratively with stakeholders to resolve data anomalies, data quality, and compliance issues in administrative data

+ Experience matching and merging disparate data sets

+ Experience using MS Excel and PowerPoint for analysis and presentation of results

**Desired Skills:**

+ Experience with fraud detection

+ Experience using data visualization tools such as Tableau

+ Experience conducting health care related research and analytics

+ Superior customer service skills working proactively and collaboratively with federal or state research, compliance, and policy staff and stakeholders to implement and enhance internal and external management reports and public-facing data analysis tools and data sets

+ Superior multi-tasking and organization skills. Must manage multiple simultaneous projects and prioritize assignments and tasks, accordingly, remaining flexible to changing priorities and new initiatives

+ Superior written and verbal skills. Must write succinctly and clearly and explain complex situations in plain English to technical and non-technical audiences

\#CMSVulnerabilityManagement

\#GDITHealthSystems

\#GDITPriority

COVID-19 Vaccination: GDIT does not have a vaccination mandate applicable to all employees. To protect the health and safety of its employees and to comply with customer requirements, however, GDIT may require employees in certain positions to be fully vaccinated against COVID-19. Vaccination requirements will depend on the status of the federal contractor mandate and customer site requirements.

We are GDIT. The people supporting some of the most complex government, defense, and intelligence projects across the country. We deliver. Bringing the expertise needed to understand and advance critical missions. We transform. Shifting the ways clients invest in, integrate, and innovate technology solutions. We ensure today is safe and tomorrow is smarter. We are there. On the ground, beside our clients, in the lab, and everywhere in between. Offering the technology transformations, strategy, and mission services needed to get the job done.

GDIT is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status, or any other protected class.

Clipped from: https://jobs.laimoon.com/jobs/externalview/36180220?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Position Description:

Mathematica applies expertise at the intersection of data, methods, policy, and practice to improve well-being around the world. We collaborate closely with public- and private-sector partners to translate big questions into deep insights that improve programs, refine strategies, and enhance understanding using data science and analytics. Our work yields actionable information to guide decisions in wide-ranging policy areas, from health, education, early childhood, and family support to nutrition, employment, disability, and international development. Mathematica offers our employees competitive salaries, and a comprehensive benefits package, as well as the advantages of being 100 percent employee owned. As an employee stock owner, you will experience financial benefits of ESOP holdings that have increased in tandem with the company’s growth and financial strength. You will also be part of an independent, employee-owned firm that is able to define and further our mission, enhance our quality and accountability, and steadily grow our financial strength. Read more about our benefits here: https://www.mathematica.org/career-opportunities/benefits-at-a-glance.

Mathematica is searching for a dedicated professional with experience successfully improving state health and Medicaid programs through the analysis of data. Experience with analyzing traditional Medicaid data (e.g., claims, encounters, beneficiary, and provider) is required. Experience or interest in analyzing additional data sources that are correlated with health outcomes, such as social determinants data, is appreciated but not required. In particular, we are looking for an individual who understands and can structure these data to answer policy-related questions and can understand data models and systems architecture that help to facilitate data analysis. We expect that this individual can apply analytic thinking to support current and emerging work across any number of areas related to state health such as: all-payer claims databases, health outcomes measurement, program or policy evaluations, data analysis, advisory services, and alternate payment models.

Duties of the Position:

 

• Leverage data and analytics to provide insights on how to answer pressing policy questions, such as the quality of health care delivered, the distribution of care across geographic locations, and the impact of care delivery models on cost.
  
• Analyze clinical quality metrics to recommend improvement opportunities
  
• Evaluate health care cost and quality measures to identify provider-focused improvement opportunities
  
• Incorporate best practices and emerging clinical approaches such as predictive risk stratification, member engagement, or complex care management to strategically inform Medicaid or general health policy
  
• Query, collect, and prepare data to produce key deliverables
  
• Provide analytics expertise to review and summarize complex reports requested by legislators or Medicaid or health care leadership
  
• Monitor and assure the organization meets contractual and CMS federal requirements
  
• Provide analytical support to produce analytic files or analytic outputs for measuring the value of health care
  
• Contribute to the growth, expertise, and institutional knowledge of other state health and Medicaid staff.
  

Functional Skills (Required):


 

• At least intermediate level of skills in statistics and analytics (including programming in SQL for data retrieval and manipulation or R for statistical modeling)
  
• Excellent understanding of health care data structures and definitions
  
• Excellent written and oral communication skills, including an ability to explain observations and findings to diverse stakeholder audiences including program administrators and policymakers
  
• Demonstrated ability to coordinate the work of multidisciplinary teams
  
• Strong organizational skills and high level of attention to detail; flexibility to lead and manage multiple priorities, sometimes simultaneously, under deadlines
  
• Ability to work well in teams
  

 
 

 
 

Position Requirements:

Qualifications (Required):

• At least 3 years full time professional work performing health care data analyses and/or directing analytic product development (e.g. reports, dashboards, etc.), with a substantial portion of that time related to state-level Medicaid data
  
• At least a bachelors degree in a related field
  
• Broad understanding of health care and health policy issues in the United States
  
• Experience in healthcare field and/or with health care quality measurement
  

Qualifications (Preferred):


 

• Experience in Tableau
  
• Experience with Business Intelligence solutions, such as Power BI.
  

Candidates with post-graduate, relevant professional experience in priority policy areas within state Medicaid or other aspects of state health, are encouraged to apply. Please attach your cover letter and resume, as well as a writing sample that demonstrates policy analysis or program operation and monitoring skills, and reflects independent analysis and writing (such as a white paper or decision memo).

Various state and federal agencies with whom we contract require that staff successfully undergo a background investigation or security clearance before working on certain projects. If you are assigned to such a project, you will be required to obtain the requisite security clearance.

This position offers an anticipated base salary of $65,000-95,000 annually. This position may be eligible for an annual bonus based on company and individual performance. Available locations: Princeton, NJ; Washington, DC; Cambridge, MA; Oakland, CA; Ann Arbor, MI; Chicago, IL; Woodlawn, MD; Seattle, WA; Remote