Description


SHIFT: Day Job


SCHEDULE: Full-time


Your Talent. Our Vision. At Amerigroup, a proud member of the Anthem, Inc. family of companies focused on serving Medicaid, Medicare and uninsured individuals, it’s a powerful combination. It’s 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.


RVP II Sr Clinical Officer (Medicaid)


Responsible for providing strategic leadership for Medicaid New York, W. New York, New Jersey, Maryland, and Virginia representing 10 billion in annual revenue. Responsible for providing clinical expertise leadership and oversight of care management in order to drive strategic priorities at the State Health Plan level. Is accountable for partnering with other health plan leaders to determine and improve factors contributing to variations in health care cost and quality.


Primary Duties May Include, But Are Not Limited To

• Sets and executes priorities to improve health care cost and quality.
• Directs staff to improve health care costs and quality for members. Interprets existing policies and develops or adopts new policies based on changes in the healthcare or medical arena. Leads, develops, directs and implements clinical and non-clinical activities that impact health care quality cost and outcomes.
• Directs and manages the Medical Management staff to ensure timely and consistent responses to members and providers. Identifies and develops opportunities for innovation to increase effectiveness and quality.
• Serves as a resource and consultant to other areas of the company as needed.
• May chair or serve on company committees and represent Anthem to external entities and/or serves on external committees and provides guidance for clinical operational aspects of the program.
• Hires, trains, coaches, counsels, and evaluates performance of direct reports and directly supervises the management of any assigned staff.
   

Reports To: VP Medicaid Clinical Ops


Staff: 9 direct reports; 12 indirect reports


Other key


Relationships: State Plan Presidents


Operations


Finance


Provider Solutions


Location: Within commuting distance to an Anthem Medicaid office.


Qualifications


Requires M.D. or D.O.; board certification approved by the American Board of Medical Specialties where applicable to duties being performed; must possess an active unrestricted medical license to practice medicine or a health profession in a state or territory of the United States. Unless expressly allowed by state or federal law or regulation must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base vessel or any embassy located in or outside of the US. 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background. Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.


Preferred

• Previous Utilization Review experience.
• Medicaid line of business experience.
• People leadership skills and experience.
  
  

Leadership Attributes
 

• Thought Leader
• Visionary and Strategic Thinker
• Strong Collaborator/Relationship Focused
• Results Oriented
• End to End Influencer
• Inspiring Leader and Developer of Talent
• People leadership experience
  
  

Applicable to Colorado Applicants Only


Annual Salary Range*: $286,020 – $357,525


Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

• The hourly or salary range is the range Anthem in good faith believes is the range of possible compensation for this role at the time of this posting. The Company may ultimately pay more or less than the posted range. This range is only applicable for jobs to be performed in Colorado. This range may be modified in the future. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company’s sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.
  
  

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.


Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

 
 

Clipped from: https://www.linkedin.com/jobs/view/rvp-ii-sr-clinical-officer-medicaid-at-anthem-inc-2696617769/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Description:

Description

SHIFT: Day Job

SCHEDULE: Full-time

 

Your Talent. Our Vision. At UniCare, a subsidiary of 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. 

 
 

RN Utilization Management – Medicaid Outpatient (PS55376)

 
 

Location: This position will allow you to work from your home office. You must reside in the state of West Virginia.

 
 

Work Hours: Regular business hours

 
 

The Nurse Medical Management l position for Unicare (Medicaid West Virginia) is responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of outpatient services and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers or programs. Works with medical directors in interpreting appropriateness of care. Primary duties may include, but are not limited to: 

 
 

• Conducts pre-certification for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract.
• Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
• Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
• Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

 
 

Qualifications

• Current active unrestricted RN license to practice as a health professional within the scope of practice in the state of West Virginia.
• Must reside in the state of West Virginia.
• 2 or more years of acute care clinical experience.
• Experience using multiple computer programs simultaneously.

 
 

• Knowledge of substance abuse disorders.

 
 

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) + match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

 
 

Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.  Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

 
 

Clipped from: https://anthemcareers.ttcportals.com/jobs/7267461-nurse-medical-management-l-telephonic-medicaid-outpatient?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Job Description

Job DescriptionThis position is responsible for actuarial support of the Louisiana Medicaid market, including pricing evaluation, reserving, forecasting and other analytical support as necessary. The actuarial team works closely with other functional areas, including Finance, Operations, Medical Management and Plan management.#AetnaActuaryRequired QualificationsExisting proficiency with Microsoft Word, Excel Demonstrated analytical and computing skills. Demonstrated initiative and perseverance Excellent oral and written communications skills.Preferred QualificationsWe are looking for individuals interested in pursuing their ASA/FSA designation(s). Progress in the exams towards the ASA designation.EducationDegree in Actuarial Science / Statistics / Mathematics, or in Computer Science / Economics / Business / Finance / Physics / Engineering with a strong math background.Business OverviewAt 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.

 
 

Clipped from: https://b-jobz.com/us/web/jobposting/258004933274?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

 
 

 
 

Job Description


Medicaid Enrollment


Team Lead


Responsibilities May Include But Are Not Limited To

• Process daily enrollee invoices and premium reconciliation for Marketplace members.
• Perform month-end invoicing and accuracy audits.
• Administer claims payments, maintain claim records, and provide counsel to claimants regarding coverage amount and benefit interpretation.
• Monitor and control backlog and workflow of claims and ensure that claims are settled in a timely fashion and in accordance with cost control standards.
• Assist in resolution of escalated premium payment issues with Appeals and Grievances team.
• Guide and collaborate with Enrollment team to resolve eligibility issues affecting premium billing.
• Ensure the accurate billing and posting of payments on accounts.
• Complete adjustments for bad debt accounts and is responsible for timely correction of posting errors.
• Verify, document and investigate the presence of health care coverage for Medicaid recipients and their families.
• Assist in the identification of members that may qualify for the HIPP/Premium Assistance program.
• Complete maintenance of active cases during open enrollment and premium review for check processing to assist with maintaining the revenue and program growth.
• Partner with enrollment teams and offer guidance where premiums are directly impacted by enrollment discrepancies.

Location for this position is Phoenix, AZ.


Qualifications


Basic
 

• High School Diploma or GED Equivalent
• At least 4 years of relevant work experience

Preferred
 

• Knowledge of basic Medicaid/Medicare billing rules, regulations, and deadline
• Must have excellent time management and organizational skills.
• Strong team-oriented individual.
• Excellent communication with all levels of team.
• Must have strong knowledge and experience in MS office products, minimally Outlook, Word and Excel.
• Access or SQL experience is a plus.
   

Note: Applicants for employment in the U.S. must possess work authorization which does not require sponsorship by the employer for a visa (H1B or otherwise).

The job entails sitting as well as working at a computer for extended periods of time. Should be able to communicate by telephone, email or face to face.

About Us

Infosys BPM, the business process management subsidiary of Infosys (NYSE: INFY), provides end-to-end transformative services for its clients across the globe. The company’s integrated IT and BPM solutions approach enables it to unlock business value across industries and service lines, and address business challenges for its clients. Utilizing innovative business excellence frameworks, ongoing productivity improvements, process reengineering, automation, and cutting-edge technology platforms, Infosys BPM enables its clients to achieve their cost reduction objectives, improve process efficiencies, enhance effectiveness, and deliver superior customer experience.

Infosys BPM has 32 delivery centers in 16 countries spread across 6 continents, with more than 38000 employees from over 80 nationalities, as of Nov 2019.

The company has been consistently ranked among the leading BPM companies globally and has received over 60 awards and recognitions in the last 5 years, from key industry bodies and associations like the Outsourcing Center, SSON, and GSA, among others. Infosys BPM also has very robust people practices, as substantiated by the various HR-specific awards it has won over the years. The company has consistently been ranked among the top employers of choice, on the basis of its industry leading HR best practices. The company’s senior leaders contribute widely to industry forums as BPM strategists.

Clipped from: https://www.linkedin.com/jobs/view/medicaid-enrolment-team-lead-at-infosys-2657395702/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

At Delta Dental, our strategy is only as strong as the people who execute it! We are hiring individuals that are not just right for today but also for our future. We have built a foundation of high-trust by treating all people with dignity, making and keeping commitments, and consistently striving to do the right thing. Our leaders optimistically share future possibilities to inspire and motivate others toward their full potential. We expect our employees to find ways to embrace positive change, be curious and challenge the status quo, and provide solutions to unmet problems. Joining Delta Dental means joining a culture focused on fostering development, building genuine connections, recognizing each other’s strengths and sharing in successes.

 
 

This position is responsible and accountable for the effective project management to implement all new and existing business along with implementing process solutions of all levels of complexity into Delta Dentals’ systems and processes for the line of business. Responsibilities of the position include collaborating with the business lines, developing and executing project plans that embrace best practices, change management, quality management, effective communication plans, requirements management, and securing all necessary resources needed to achieve the project objectives.

 
 

How you will make an impact:

• Acts as key partner to the line of business: understands strategic goals, customer needs and business objectives; acts as liaison between the line of business and Sales Shared Services and cross-functional partners involved in implementation.
• Plans, documents and executes all phases of the project lifecycle, including scope management, requirements management, work breakdown schedule and timeline management, priority and dependency management, and the assignment of roles and responsibilities.
• Performs risk management to minimize project risks.
• Develops detailed work breakdown schedules, project estimates, and resource plans that support scope.
• Develops comprehensive project plans to be shared with clients as well as other staff members.
• Conducts and facilitates effective project meetings, including issue tracking, status reports, and executive communications.
• Ensures problems are effectively escalated and crisis management activated, as needed.
• Manages changes to the project scope and project schedule.
• Acts as an advocate for the business, by providing first class service through expert development of the project management discipline.
• Lends subject matter expertise and knowledge management to the project team and stakeholders and ensures customer satisfaction through quality and timely product delivery.
• Promotes change, process, and best practices to both the business and technical team members, providing training for the project management discipline.
• Leads the project team on development efforts and lends both functional and technical system-specific knowledge throughout the project lifecycle.
• Provides advice and guidance to less experienced staff and assists in resolving escalated complex issues/problems, as needed.
• May attend in person finalist presentations and represents implementation.
• May lead in person implementation kick off meetings with external clients and brokers.
• Leads implementation kick off meetings with cross-functional partners.
• Uses and continually develop leadership skills.
• Performs miscellaneous duties as assigned.

What we look for:

• A Bachelor’s degree preferred. Equivalent experience may be considered in lieu of degree.
• A minimum of 6 years related experience.
• 2+years of industry experience onboarding Medicaid and Medicare (CMS) with demonstrated experience leading onboarding projects.
• PMP Certification would be preferred but not required.
• Ability to understand customer needs.
• Detail orientation and problem-solving abilities.
• Strong Presentation Skills.
• Advanced analytical and problem-solving skills to evaluate business processes and recommend effective solutions.
• Advanced organizational/time management and project management skills and multi-tasking abilities.
• Advanced knowledge of project development life cycle, including the ability to coordinate and prioritize multiple complex projects and cost analysis.
• Knowledge of Delta Dental products, policies, claims, eligibility and underwriting guidelines.
• Ability to coordinate issues between internal and external clients and the development teams.
• Ability to identify non-standards and foster creative solutions.
• Expert knowledge of project development life cycles, including the ability to coordinate and prioritize multiple projects.
• Excellent client-facing and internal communication skills.
• Strong leadership skills to lead the project team.

Benefits and perks:

• 12 days starting vacation plus 12 holidays and your birthday off!
• Multiple medical insurance options: 100% paid or low cost premiums
• 100% paid dental insurance
• 100% paid vision insurance
• Employee Well-Being Program
• Culture of learning: substantial tuition reimbursement to improve your skills
• Career growth: we love promoting from within
• Strong commitment to work/life balance
• Social responsibility and volunteer opportunities

Due to COVID-19, there is an even greater demand for flexibility and change. As Delta Dental navigates our Return-to-Office strategy, the expectation around work location for certain roles may be offsite until a future date, determined by Delta Dental Management. Should the position you seek be determined by Delta Dental Management to begin your duties offsite, the position would require you to have access to internet in order to meet the expectations outlined in the job duties.

 
 

Please note, Delta Dental will not sponsor applicants for work visas for this position.

 
 

#LI-LS1

 
 

At Delta Dental we:

Promote accountability, integrity and collaboration: Our employees are collaborative, self-aware, and ethical. It is our expectation to do the right thing and follow through on commitments.

Foster professional development: Our employees take ownership of developing themselves and others through coaching, mentoring and providing/being open to constructive feedback and identifying learning opportunities.

Value customers and cultivate positive experiences: Our employees take time to build rapport with customers, while anticipating and exceeding their needs to ensure positive outcomes.

 
 

If you think this sounds like you, let’s chat. We would love to tell you more!

 
 

To see some of the smiling faces behind Delta Dental and to learn more about what our values and culture look like in action, connect with us on social media: @lifeatddins on and , @deltadentalins on , and Delta Dental Ins. on .

ABOUT Delta Dental

Delta Dental covers more Americans than any other dental benefits provider. Our vision is to motivate and empower every employee so we’re all inspired to take exceptional care of our customers, providers and each other. Our Enterprise Strategy focuses on pillars of Growth and Diversification, supported by the platforms of Culture and People, Process and Technology. Our employees take pride working for a purpose-driven organization and live our values of Trust, Service, Excellence and Innovation.

We are part of the Delta Dental Plans Association, a network of companies that provides dental coverage to 74 million people in the U.S. Delta Dental of California, Delta Dental of New York, Inc., Delta Dental of Pennsylvania and Delta Dental Insurance Company, together with our affiliate companies, form one of the nation’s largest dental benefits delivery systems, covering 33 million enrollees. All of our companies are members, or affiliates of members, of the Delta Dental Plans Association, a network of 39 Delta Dental companies throughout the country.

Delta Dental provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, genetics, or any other classification protected by federal or state law. In addition to federal law requirements, Delta Dental complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

 
 

Unfortunately, our Delta Dental Enterprise is unable to hire individuals residing in Alaska, North Dakota, Nebraska, Hawaii, Oklahoma, Vermont, Maine, West Virginia, New Hampshire, Wyoming, Puerto Rico or other US Territories at this time.

 
 

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HC FINANCIAL CONSULTANT

AHCCCS

The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, is driven by its mission to deliver comprehensive, cost-effective health care to Arizonans in need. AHCCCS is a nationally acclaimed model among Medicaid programs, and a recipient of multiple awards for excellence in workplace effectiveness and flexibility. Among government agencies, AHCCCS is recognized for high employee engagement and satisfaction, supportive leadership, and flexible work environments, including remote work opportunities. With career paths for seasoned professionals in a variety of fields, entry-level positions, and internship opportunities, AHCCCS offers meaningful career opportunities in a competitive industry. AHCCCS employees are passionate about their work, committed to high performance, and dedicated to serving the citizens of Arizona.

HC Financial Consultant

AHCCCS
 

Posting Details:

Salary: $60,000 – $70,000 
 

Grade: 23

Job Summary:

The Division of Health Care Management (DHCM) is looking for a highly motivated individual to join our team as a HC Financial Consultant. This position in on the AHCCCS Actuarial Team. The successful candidate will assist the team with capitation rate development, and help monitor the financial stability of the Contractors that provide medical care to members for five programs.

Job Duties:

* Preparation of financial, encounter and any additional analysis to support the AHCCCS Actuaries.

* Preparation of all program reconciliations including calculation of directed payments.

* Preparation of the Rural Hospital Payment.

* Databook liaison.

* Preparation of Capitation and reconciliation information for the Contractors and the AHCCCS website.

* Other duties as assigned as related to the position

 

Knowledge, Skills & Abilities (KSAs):

* Financial Analysis principles;

* Accounting and financial reporting

* Health Care programs and principles and models of prepaid health programs

* Audits or reconciliations.

* Project Management Skills

* Financial statement review and analysis

* Work independently.

 

Selective Preference(s):

* Finance or accounting related degree, C.P.A. or Master’s level degree preferred.

* Experience with Medicaid managed health care programs preferred.

* Combination of five years’ experience with capitation rate setting or financial analysis required.

Clipped from: https://jobs.azahcccs.gov/hc-financial-consultant/job/17121645?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

Description


The Provider Contracting Executive initiates, negotiates, and executes physician, hospital, and/or other provider contracts and agreements for an organization that provides health insurance. The Provider Contracting Executive works on problems of diverse scope and complexity ranging from moderate to substantial.

Responsibilities


The Provider Contracting Executive for Ohio Medicaid will communicate contract terms, payment structures, and reimbursement rates to providers. You will be responsible for Ohio Medicaid compliance with network adequacy standards. Maintains familiarity with Ohio Medicaid fee schedules and analyzes comparable Plan pricing guidelines. Ensures capitation, provider rosters, and RHC/FQHC reports are monitored and strategies are developed and plans are implemented to address outliers. Remains current in all aspects of Federal and State rules, regulations, policies and procedures and creates or modifies departmental policies to reflect changes. You will analyze financial impact of contracts and terms. Maintain contracts and documentation within a tracking system. Will identify and recruiting providers based on network composition and needs. Advise executives to develop functional strategies (often segment specific) on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision. Uses independent judgment requiring analysis of variable factors and determining the best course of action.

Required Qualifications
 

• Bachelor’s degree
• Knowledgeable of Ohio Medicaid compliance with network adequacy standards
• Experience negotiating fee for service & capitated reimbursement methodologies for Hospital, Ancillary and Providers specific to Ohio Medicaid methodologies
• Experience communicating the implementation of capitation payments, provider rosters, and RHC/FQHC reports to internal load teams, able to address outliers with provider community
• 5 or more years of progressive network management experience including hospital contracting and network administration in a healthcare company
• 2 or more years of project leadership experience
• Minimum 1-2 years Ohio Medicaid experience
• Extensive provider contracting skills, including contract preparation and implementation, financial analysis and rate proposal development
• Excellent written and verbal communication skills and experience presenting to varied audiences
• Ability to manage multiple priorities in a fast-paced environment
• Knowledge of Microsoft Office applications
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

 

• Master’s Degree
• Experience with ACO/Risk Contracting
• Experience with Value Based Contracting

Additional Information


This position is considered “remote/work at home”, however, you must live in Ohio to be considered for this opportunity.

Work at Home/Remote Requirements Must ensure designated work area is free from distractions during work hours and virtual meetings Must provide a high-speed DSL or cable modem for a workspace (Satellite and Hotspots are prohibited). A minimum standard speed of 10×1 (10mbs download x 1mbs upload) for optimal performance of is required

Scheduled Weekly Hours


40

1 day ago

 
 

Clipped from: https://us.trabajo.org/job-605-20210815-99ac399d00cbb85274af9c632378dc35?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

About NYC Health + HospitalsMetroPlus Health provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. Position Overview
Reporting to the Head of Product, the Director of Medicaid ensures operational excellence and regulatory compliance of all Medicaid products, owning the full spectrum of product strategy and operations. The Director will support key analytical activities to support the Plan s strategic position, and will be proactive in identifying opportunities for performance improvement.Job Description Provide oversight of Plan and vendor operations as they relate to the Medicaid line of business aligning outcomes to strategic goals & regulatory requirements.
Develop & manage operational reports to track operational effectiveness.
Partner with operational departments including Claims, Customer Service, Finance, Enrollment, Vendor Management, & Medical Management to design processes ensuring effective & efficient operations.
Support key stakeholders in driving initiatives to meet quality & customer satisfaction goals.
Maintain customer focus throughout Plan operations to ensure a seamless & excellent customer experience.
Provide deep knowledge of & insight into the regulatory & market environment of Medicaid in New York to support the development of product strategy.
Identify & integrate operational best practices, partnering with key departments to optimize processes across the organization such as benefits administration, risk adjustment, marketing & communications, customer experience.
Monitor & analyze regulatory activity ensuring compliant operations & implementation.
Perform competitive & market analysis.
Partner with internal & external stakeholders on key strategic, regulatory, & operational projects.Minimum Qualifications Bachelor s degree from an accredited college or university in an appropriate discipline required.
Master s degree in business, healthcare or public administration strongly preferred.
Minimum 5 years experience at a Health Plan with Medicaid Managed Care in a product management or compliance role.
Thorough knowledge of Medicaid regulatory environment in NYS.
Experience working with NYS enrollment transactions & encounter data submissions.
Thorough understanding of interconnected managed care operations
Demonstrated ability to develop workflows, policies, procedures.
Demonstrated ability to identify opportunities for improvement & implement solutions.
Excellent written & verbal communication skills.
Excellent analytical skills demonstrated by an ability to use actionable data to support decisionmaking, and to proactively identify opportunities.
Highly collaborative, and demonstrating good judgment in seeking consensus & input from multiple stakeholders to drive decision-making.
Ability to take initiative & think independently
Demonstrate understanding & acceptance of the MetroPlus Mission, Vision, & ValuesProfessional Competencies Leadership
Results-driven
Business acumen
Systems orientation
Process improvement
Data-driven decision-making
Customer focus
Written/oral communication
Resourcefulness
Ability to work effectively in a fast-paced & constantly evolving environment Associated topics: broker, client, guest, health, lead sales agent, outside sales, phone, sales agent, sales professional, sell

 
 

Clipped from: https://www.snagajob.com/jobs/639661168?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Description


Humana’s Louisiana Medicaid BH Medical Director will oversee our behavioral health (BH) clinical program for Louisiana Medicaid plan members. They will collaborate closely with the Chief Medical Officer (CMO) to integrate the day-to-day administration and strategic management of behavioral and physical health services, including utilization management (UM), quality improvement, and value-based payment programs. The BH Medical Director will be based in Louisiana and will also lead the development of new products and services in Humana’s Medicaid BH delivery model.

Responsibilities


Essential Functions and Responsibilities
 

• Lead major clinical and quality management components of Humana’s BH services
• Oversee, monitor, and assist with the management of psychopharmacology pharmacy benefits manager (PBM) activities, including the establishment of Prior Authorization, clinical appropriateness of use, and step therapy requirements for the use of stimulants and antipsychotics for all Enrollees under the age of eighteen (18); consultations and clinical guidance for contracted Primary Care Providers (PCPs) treating behavioral health-related concerns not requiring referral to behavioral health specialists;
• Develop comprehensive care programs for the management of youth and adult behavioral health concerns typically treated by PCPs, such as ADHD and depression;
• Develop targeted education and training for contracted PCPs to screen for mental health and substance use disorders using evidence-based tools (e.g., AUDIT-C, PHQ-9 and GAD-7), perform diagnostic assessments, provide counseling and prescribe pharmacotherapy when indicated, and build collaborative care models in their practices;
• Coordinate with the Medical Director to integrate the administration and management of behavioral and physical health services;
• Oversee, monitor and assist with effective implementation of the Quality Management (QM) program; and work closely with the Utilization Management (UM) of services and associated Appeals related to children and youth and adults with mental illness and/or substance use disorders (SUD)
• Lead BH policy development in Louisiana, driving implementation, oversight, and accountability for both Humana internal and external stakeholders

 
 

• Adhere to and comply with federal and state laws and programmatic requirements
• Collaborate with provider relations personnel to ensure high-quality and appropriate care delivered through the BH provider network
• Establish and maintain relationships with providers, advocates, and other key Louisiana stakeholders by maintaining open and ongoing communications; represent Humana at public forums and engagement opportunities
• Maintain compliance with BH-related contract requirements and attend oversight committee meetings to ensure appropriate procedures are adhered to within Humana and within care delivery
• Collaborate closely with corporate and local population health teams in developing programs and strategies to address BH needs at a population health level

Required Education, Certification, & Experience Qualifications
 

• Physician with a current, unencumbered Louisiana-license as a physician
• Board-certified in psychiatry
• At least three (3) years of training in a medical specialty
• Knowledge of the managed care industry
• Possess analysis and interpretation skills with prior experience leading teams focusing on quality management, UM, discharge planning and/or home health or rehab

Preferred Experience Qualifications

 

• Five (5) years or more clinical experience working in BH
• Familiarity with Louisiana-based BH organizations
• Medicaid Managed Care clinical or behavioral health leadership experience

Additional Information

Typically reports to a Regional Vice President of Health Services, Lead, or Corporate Medical Director, depending on size of region or line of business. The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type. May also engage in grievance and appeals reviews. May participate on project teams or organizational committees.

#physiciancareers

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Job Summary:

• Identify, pursue, and win State Healthcare/Medicaid/Human Services/Public Health complex deals up to $100M TCV and above.
• Lead pursuit teams for complex sales efforts with resources which include a proposal manager, solution architect, legal resources, etc.
• Lead pursuit team in developing and substantiating a winning value proposition that meets the needs of the customer, including analyzing critical business drivers and risks.
• Develop deal timeline and ensure that pursuit team meets deal milestones and deadlines.

 
 

Knowledge and Skills Required:

• Industry knowledge in State Government Healthcare/ Medicaid, Human Services or Payer and State and Local
• Know how to integrate different solutions to create unique and innovative solutions for the customer.
• In-depth customer knowledge – policy, politics, strategies, and challenges.
• Business/financial management acumen.
• Strong Business Analytics background preferred.
• Familiarity with project management methodologies.
• Ability to leverage and work with Industry Partners or Third-Party Alliances where applicable.
• Leadership skills in directing pursuit and/or delivery teams.
• Highly developed consultative approach, solution selling and business development skills.
• Business and customer-oriented team player with ability to form alliances across boundaries.
• Able to sell and negotiate deals where the company is not the low-cost provider.
• Strong influencing and communication skills at a Secretary/Director/CIO level.
• Required personal characteristics: high integrity, intelligence, critical thinking maturity, high energy, strong work ethic, ability to energize others, demonstrated ability to consistently execute, passion to succeed.

Education and Experience Required:

• Typically 5+ years directly related experience in Outsourcing and/typically 10+ years in complex IT service business environment.
• New logo (hunter) sales and closer experience – must be able to demonstrate sales success.

Clipped from: https://us.trabajo.org/job-1155-20210815-39a716d5fea8f5a9e69a4cc20800661f?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic