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Back to search: Ohio Medicaid / Cincinnati, OH

Cincinnati, OH – Ohio

Humana

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full time

Published on www.appcast-cpc.com 14 Mar 2023

DescriptionThe Inbound Contacts Representative 2 represents the company by addressing incoming telephone, digital, or written inquiries. The Inbound Contacts Representative 2 performs varied activities and moderately complex administrative/operational/customer support assignments. Performs computations. Typically works on semi-routine assignments.ResponsibilitiesThe Inbound Contacts Representative 2 addresses customer needs which may include complex benefit questions, resolving issues, and educating members. Records details of inquiries, comments or complaints, transactions or interactions and takes action accordingly. Escalates unresolved and pending customer grievances. Decisions are typically focus on interpretation of area/department policy and methods for completing assignments. Works within defined parameters to identify work expectations and quality standards, but has some latitude over prioritization/timing, and works under minimal direction. Follows standard policies/practices that allow for some opportunity for interpretation/deviation and/or independent discretion. Required Qualifications: Minimum 2 years of customer service experience. Demonstrated experience with providing exceptional customer service and attention to details while listening on calls. Prior experience managing multiple or competing priorities, including use of multiple computer applications simultaneously. Prior experience effectively communicating with customers verbally and listening to their needs. Must be able to accurately and completely document member needs, inquiries, or questions during calls within multiple systems. Location: MUST reside in the State of Ohio Required Work Schedule: This role starts on April 17, 2023. Virtual Training will start day one of employment and runs for the first 7 weeks with a schedule of 8:00 am – 4:30 pm EST, Monday – Friday. Attendance is vital for success, so no time off is allowed during training or within your first 120 days, with the exception of observed (and paid) company holidays. Following training, must be available to work any 8-hour shift between the hours 6:45 am – 8:00 pm EST, Monday – Friday (subject to change based on business needs). Some weekends and overtime may be required based on business needs. Preferred Qualifications: What you need to STAND OUT among the crowd: Associates or Bachelors Degree Prior inbound call center or related customer service experience Prior healthcare experience Bilingual in English and Spanish (potential increase in hourly rate for bilingual skills; see Additional Information below) Proficiency with Microsoft Office applications, particularly Outlook and MS Teams Additional Information Please be advised, any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government. Candidates must be tested in ALL languages listed on the description. Work at Home GuidanceTo ensure Home or Hybrid Home/Office associates ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.Satellite, cellular and microwave connection can be used only if approved by leadership.Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.Additional InformationPlease be sure to include your resume with your application!As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Modern Hire to enhance our hiring and decision-making ability. Modern Hire allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. If you are selected for a first round interview, you will receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isnt missed) inviting you to participate in a Modern Hire interview. In this interview, you will listen to a set of interview questions over your phone and you will provide recorded responses to each question. You should anticipate this interview to take about 15 to 30 minutes. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews. ALERT : Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide a Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions to add the information into the application at Humanas secure website. #LI-REMOTEScheduled Weekly Hours40

Clipped from: https://www.indeed.com/viewjob?jk=fc49d4e19b131329&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Benefits

Pulled from the full job description

401(k)

401(k) matching

AD&D insurance

Dental insurance

Dependent health insurance coverage

Disability insurance

Employee assistance program

Health insurance

Paid sick time

Paid time off

Tuition reimbursement

Vision insurance

Wellness program

Tooth be told, you’ll love working with us.

LIBERTY Dental Plan is seeking a Vice President to provide strategic oversight of business development and generate new business opportunities by strategizing, qualifying and identifying secure business opportunities that will positively impact the growth and profitability of the company.

JOB SUMMARY

• Plans and coordinates LIBERTY’s business development strategy, in accordance with organizational goals.
  
• Identifies new business opportunities and manages relationships through the business development lifecycle.
  
• Strengthen existing and new business relationships using a working knowledge and understanding of the industry, client regulatory requirements, and LIBERTY’s operations and innovation.
  
• Build and manage a high-performing national sales team.
  
• Represent LIBERTY at industry conferences, trade shows, events, and client meetings across the U.S.
  
• Develop and maintain positive organizational culture, values and reputation in its markets and with all staff, clients, providers, partners and regulatory/official bodies.
  
• Perform other duties as assigned.
  

WHAT YOU’LL NEED

• Minimum 14 years’ experience in business development and sales; preferably in government programs with focus on Medicaid or Managed Care
  
• Minimum 4 Year bachelor’s degree in business, Marketing or related, or equivalent combination of experience and education.
  
• Strong negotiation and influential skills
  
• Strong understanding of the health insurance industry and Medicaid/Medicare Advantage, dental highly preferred
  
• Previous corporate sales and/or consulting expertise required
  
• Management skills – prior experience in sales leadership required
  
• Client relationship skills – ability to develop strong professional relationships
  
• Effective communication (verbal and written) and presentation skills
  
• Results driven – focused on producing high-quality services and deliverable
  
• Computer literacy with ability to easily acquire working knowledge of new system applications. Possess, at minimum, basic Microsoft (Excel, Word and PowerPoint) skills
  

LOCATION

Near one of our primary offices is highly preferred. LIBERTY offices are located in Irvine, CA, Las Vegas, NV, Oklahoma City, OK and Tampa, FL. Our employees are distributed in office locations in multiple markets across the United States. We are unable to hire or allow employees to work outside of the United States.

WHAT LIBERTY OFFERS

Happy, healthy employees enhance our ability to assist our members and contribute more actively to their society. That’s why LIBERTY offers competitive and attractive benefit packages for their employees. We strive to care for employees in positive ways that promotes wellness and productive employees.

Our first-class benefit package supports our employees and their dependents with:

• Competitive pay structure and saving options that help you reach your financial goals!
  
• Excellent 401k plan that matches 100% up to 3%. 50% match at 4% and 5%; immediate vesting during Safe Harbor period and professional financial advice through Financial Engines!
  
• Medical Insurance at no charge for employee only coverage. LIBERTY subsidizes 50% of eligible dependent coverage! Company offers PPO and HMO (where available) options.
  
• 100% paid dental coverage for your ENTIRE eligible Family members!
  
• 100% paid vision coverage for employee only coverage, low premium for dependents!
  
• Company paid basic life and AD&D coverage; options to elect additional supplemental coverage.
  
• Long Term Disability coverage
  
• Generous wellness program
  
• Employee Assistance Program
  
• 10 days paid vacation, 10 paid holidays including 2 days each for Thanksgiving, Christmas and New Years and a floating holiday granted for your birthday!
  
• 6 paid sick days annually with the ability to roll time over!
  
• Tuition Reimbursement
  
• Remote or Hybrid options for various positions
  
• And so much more…
  

COMPENSATION

In the spirit of pay transparency, we are excited to share the base salary for this position is $200,000 – $283,634, exclusive of fringe benefits or potential bonuses. If you are hired at LIBERTY, your final base salary compensation will be determined based on factors such as geographic location, skills, education, and/or experience. In addition to those factors – we believe in the importance of pay equity and consider internal equity of our current team members as a part of any, final offer. Please keep in mind that the range mentioned above is the full base salary range for the role. Hiring at the maximum of the range would not be typical in order to allow for future & continued salary growth.

LIBERTY Dental Plan commits to maintaining a work environment that acknowledges all individuals within the workplace and will continue to engage in practices that are inclusive of all backgrounds, experiences, and perspectives. We strive to have every person within the organization have a sense of belonging while encouraging individuals to unleash their full potential. LIBERTY will leverage diverse perspectives in building high performance teams and organizational culture.

LIBERTY Dental Plan will continue to strengthen and develop external partnerships by providing equitable health care access and improving population health in the communities we serve.

We comply with all applicable laws and regulations on non-discrimination in employment, recruitment, promotions, and transfers, as well as work authorization and employment eligibility verification requirements.

Sponsorship and Relocation Specifications:

LIBERTY Dental Plan is an Equal Opportunity Employer / VETS / Disabled.

No relocation assistance or sponsorship available at this time.

Clipped from: https://www.ziprecruiter.com/c/State-of-Louisiana/Job/MEDICAID-REGIONAL-ADMINISTRATOR/-in-Baton-Rouge,LA?jid=7f02a1b94d9033fa&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

This position is located within the Louisiana Department of Health / Medical Vendor Administration / Tangipahoa Parish


Announcement Number: MVA/PJ/172991
Cost Center: 305-2050410
Position Number(s): 50381201


This vacancy is being announced as a Classified position and may be filled as a Probationary or Promotional appointment.


No Civil Service test score is required in order to be considered for this vacancy.


To apply for this vacancy, click on the “Apply” link above and complete an electronic application, which can be used for this vacancy as well as future job opportunities. Applicants are responsible for checking the status of their application to determine where they are in the recruitment process. Further status message information is located under the Information section of the Current Job Opportunities page.


*Resumes WILL NOT be accepted in lieu of completed education and experience sections on your application. Applications may be rejected if incomplete.*


A resume upload will NOT populate your information into your application. Work experience left off your electronic application or only included in an attached resume is not eligible to receive credit


For further information about this vacancy contact:
Paula Jackson

paula.jackson@la.gov
LDH/HUMAN RESOURCES
BATON ROUGE, LA 70821
225 342-6477


This organization participates in E-verify, and for more information on E-verify, please contact DHS at 1-888-464-4218.

MINIMUM QUALIFICATIONS:

A baccalaureate degree plus five years of professional level social services experience, two years of which must have been as a supervisor of two or more professionals.

SUBSTITUTIONS:
Six years of full-time work experience in any field may be substituted for the required baccalaureate degree.

Candidates without a baccalaureate degree may combine work experience and college credit to substitute for the baccalaureate degree as follows:

A maximum of 120 semester hours may be combined with experience to substitute for the baccalaureate degree.

30 to 59 semester hours credit will substitute for one year of experience towards the baccalaureate degree.
60 to 89 semester hours credit will substitute for two years of experience towards the baccalaureate degree.
90 to 119 semester hours credit will substitute for three years of experience towards the baccalaureate degree.
120 or more semester hours credit will substitute for four years of experience towards the baccalaureate degree.

College credit earned without obtaining a baccalaureate degree may be substituted for a maximum of four years full-time work experience towards the baccalaureate degree. Candidates with 120 or more semester hours of credit, but without a degree, must also have at least two years of full-time work experience tosubstitute for the baccalaureate degree.

Graduate training will substitute for a maximum of one year of the required general work experience on the basis of thirty semester hours for one year of experience.

A master’s degree will substitute for one year of the required general experience.

A Juris Doctorate will substitute for one year of the required general experience.

Graduate training with less than a Ph.D. will substitute for a maximum of one year of the required general experience.

A Ph.D. will substitute for two years of the required general experience.

Advanced degrees will substitute for a maximum of two years of the required general experience.

NOTE:
Any college hours or degree must be from an accredited college or university.

FUNCTION OF WORK:

To serve as administrator for a region of the state.

LEVEL OF WORK:

Administrator.

SUPERVISION RECEIVED:

A Medicaid Regional Administrator typically reports to a Program Manager 4-DHH. May receive supervision from higher level personnel.

SUPERVISION EXERCISED:

Subordinate staff typically includes an Assistant Medicaid Regional Administrator. May supervise lower level personnel.

LOCATION OF WORK:

Department of Health and Hospitals, Medical Vendor Administration.

JOB DISTINCTIONS:

Differs from Medicaid Assistant Regional Administrator by the presence of overall responsibility for Medicaid eligibility activities in a region.

Differs from Program Manager 4-DHH by the absence of statewide responsibility for all Medicaid eligibility activities.

EXAMPLES BELOW ARE A BRIEF SAMPLE OF COMMON DUTIES ASSOCIATED WITH THIS JOB TITLE. NOT ALL POSSIBLE TASKS ARE INCLUDED.

Directs the regional execution of Medicaid programs by establishing priorities, evaluating efficiency, quality and compliance with federal and state regulations, and taking corrective action as necessary.

Directs the preparation of regional annual budget requests, oversees fiscal matters (payroll, purchasing, procurement, leasing, etc.) and physical plant management for a regional facility and all local branch units within a region.

Interviews, hires and evaluates staff and recommends and/or approves the appointment, promotion, discipline or dismissal of staff in accordance with applicable rules.

Proposes recommendations concerning staffing needs and assesses the effects of established caseload standards upon staff performance and productivity.

Coordinates the operation of programs and the work of various disciplines throughout the region.

Serves as liaison with representatives of local, state, federal and private agencies and organizations, the general public, and governmental officials.

Oversees the planning and implementation of staff development programs throughout the region.Employment Type: Classified

Clipped from: https://www.learn4good.com/jobs/online_remote/info_technology/2176578843/e/

Position:  SAS Programmer II (Medicaid)
Overview

AIR is currently seeking a Medicaid SAS Programmer II to join our Health team. The SAS Programmer II will be highly proficient in the application of SAS programming to administrative health data. The ideal candidate will participate in all aspects of AIR’s current projects. Primary responsibilities include performing a variety of tasks related to data collection, statistical and qualitative data analysis, report writing, and data manipulation.

Our Health team works collaboratively to unravel the intertwined challenges of health care quality, costs, and access. Our team of experts – nurses, physicians, psychologists, economists, sociologists, data scientists, and public health experts – advance evidence and save lives by leading rigorous research and evaluation; results-driven technical assistance and training; and leading-edge data science and technology tools.

Use your experience, knowledge, and education to help us deliver on our mission: to contribute to a better, more equitable world.

Candidates hired for the position may work remotely within the United States (U.S.) or from one of our U.S. office locations.

About AIR:

Established in 1946, with headquarters in Arlington, Virginia, AIR is a nonpartisan, not-for-profit institution that conducts behavioral and social science research and delivers technical assistance to solve some of the most urgent challenges in the U.S. and around the world. We advance evidence in the areas of education, health, the workforce, human services, and international development to create a better, more equitable world.

AIR’s commitment to diversity goes beyond legal compliance to its full integration in our strategy, operations, and work environment. At AIR, we define diversity broadly, considering everyone’s unique life and community experiences. We believe that embracing diverse perspectives, abilities/disabilities, racial/ethnic and cultural backgrounds, styles, ages, genders, gender identities and expressions, education backgrounds, and life stories drives innovation and employee engagement. Learn more about AIR’s Diversity, Equity, and Inclusion Strategy and hear from our staff by clicking here.

Responsibilities

The responsibilities for the position include:

* Convert datasets among SAS, STATA, mainframe databases and other formats

* Extract, recode, merge, and de-duplicate datasets

* Perform outlier analyses, handle missing data, and create analysis variables

* Perform statistical analyses

* Create customized reports of data analysis results

* Create quality computer generated data listings, summary tables and data collection studies

* Provide technical oversight and training to junior SAS Programmers

* Analyze code to find causes of errors and revise programs

* Write and maintain documentation of changes to computer code, programs, and specifications

* Write technical reports and proposals

* Performing other related duties as assigned

Qualifications

Education , Knowledge, and

Experience:

* Undergraduate degree in Statistics, Epidemiology, Economics, Public Health, or Date Science

* 3 years’ experience working directly with Medicaid administrative claims data

* Highly experienced in writing programming code to produce logic checks, derived datasets, summary tables, and figures for data collected via project work

* 5 years hands-on SAS experience

* Experience with CMS Medicaid and Medicare research identifiable files (RIF) data and working in the CMS virtual research data center (VRDC) environment preferred but not required

* Proposal preparation and management experience helpful but not required

* SAS certification preferred but not required

* Experience applying SAS in a health research environment preferred but not required

* Skills:

* Skilled in all aspects of data processing management

* Excellent organizational skills

* Good communication skills

* Able to learn quickly and work in a team, collaborative environment

Disclosures:

AIR requires all new hires to be fully vaccinated against COVID-19 or receive a legally required exemption from AIR, as a condition of employment. AIR will ask candidates to verify their vaccination status only after a conditional offer of employment is made. Applicants should not provide information about their vaccination status or need for exemption prior to receiving a conditional offer of employment from AIR

Applicants must be currently authorized to work in the U.S. on a full-time basis. Employment-based visa sponsorship (including H-1B sponsorship) is not available for this position. Depending on project work, qualified candidates may need to meet certain residency requirements.

All qualified applicants will receive consideration for employment without discrimination on the basis of age, race, color, religion, sex, gender, gender identity/expression, sexual orientation, national origin, protected veteran status, or disability.

AIR adheres to strict child safeguarding principles. All selected candidates will be expected to adhere to these standards and principles and…

Clipped from: https://www.glassdoor.com/job-listing/associate-medicaid-operations-specialist-blue-cross-blue-shield-of-illinois-montana-new-mexico-oklahoma-and-texas-hcsc-JV_IC1128808_KO0,40_KE41,118.htm?jl=1008530821209&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

At HCSC, we consider our employees the cornerstone of our business and the foundation to our success. We enable employees to craft their career with curated development plans that set their learning path to a rewarding and fulfilling career.

Come join us and be part of a purpose driven company who is invested in your future!

Job Summary

This position is responsible for providing assistance to the Medicaid operations specialist on operational services, works with Medicaid operational specialist with program implementation and coordination for one or more of the day-to-day Medicaid operation functions (eg billing, claims enrollment, encounter submissions and customer service). This associate is responsible for assisting the Medicaid operations specialist on researching to resolve complex and / or escalated internal or external operational questions. Additionally, this position works with other areas of the organization on the development, testing, and implementation of program policies, business processes, and system changes to ensure the state requirements of the plan are met.

JOB REQUIREMENTS:

• Bachelor Degree in Business with 1-year experience OR 5 years of experience working in health insurance operations.
  
• Experience interfacing with internal clients, customers and operations personnel.
  
• Verbal and written communication skills and ability to assist in representing Medicaid department at committee meetings.
  
• Experience with interacting effectively with all levels of internal and external customers.
  
• Experience managing multiple projects effectively.
  
• Interpersonal, organizational and analytical skills.
  
• Experience with claims, customer service and membership services
  
• Experience with analytics
  
• Organizational skills.
  

PREFERRED JOB REQUIREMENTS:

• Member encounters and reconciliation
  

Please note: This role will work in the office three days a week.

We encourage people of all backgrounds and experiences to apply. Even if you don’t think you are a perfect fit, apply anyway – you might have qualifications we haven’t even thought of yet

Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!

HCSC Employment Statement:

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

Clipped from: https://www.linkedin.com/jobs/view/medicaid-eligibility-business-sme-at-ntt-data-services-3527654163/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Req ID: 233018


NTT DATA Services strives to hire exceptional, innovative and passionate individuals who want to grow with us. If you want to be part of an inclusive, adaptable, and forward-thinking organization, apply now.


We are currently seeking a Medicaid Eligibility Business SME to join our team in Nashville, Tennessee (US-TN), United States (US).


The Medicaid Eligibility Subject Matter Expert (SME) will work directly with the client’s operations staff to assist with ongoing system enhancement work. This includes but is not limited to participation in definition, design, testing and implementation of changes in each of the system releases. This Medicaid Eligibility SME will be a valued member of the client’s Business Services Support team. The Medicaid Eligibility SME will work collaboratively with the client and other vendors on the client’s projects and initiatives. The Medicaid Eligibility SME will provide valuable business analysis services and subject matter expertise through consultation with the client. The Medicaid Eligibility SME will integrate seamlessly with the client team to ensure that business needs are met by managing and driving change using knowledge and experience.


The Medicaid Eligibility SME will assist the team with implementing these changes driven by requirements definition through final implementation and stabilization. The NTT DATA staff will perform the follow responsibilities:

• Work collaboratively with the Member Services team(s) leveraging their Eligibility business operations skills and expertise as well as their systems implementation experience, to improve the operational efficiency of the team and increase the quality of the systems enhancements and changes that go into production.
  
• Work collaboratively with the Member Services Partner Support team supporting onboarding and administrative tasks, including trouble shooting and problem solving.
  
• Participate in identifying any operational impacts created by proposed system changes and recommend modifications to business workflow and processes.
  
• Participate in requirements definition and design, business workflow development, design, and improvement, the review of system integration test case and results, and the review of user acceptance test case and results.
  
• Participate in implementation planning and execution activities, such as operational readiness tests, parallel tests, and beta tests.
  
• Develop and execute Eligibility Business Operations Test Cases as part of the User Acceptance phase for each system release.
  
• Collaborate with the Enterprise Testing Management Office (eTMO) to ensure that testing standards and processes are maintained as the Eligibility Business Operations Test Cases are executed and defects are identified.
  
• Employee is expected to undertake any additional duties as they are assigned by their manager.
  
   
  

Basic Qualifications:

• Bachelor’s degree or 4 Years additional equivalent experience
  
• Minimum of 5 years of experience including:
  
• A minimum of 3 years’ experience conducting meetings and making presentations
  
• A minimum of 2 years’ experience demonstrating strong problem-solving and customer service skills
  
• A minimum of 1 year of business experience working on large complex system implementation and/or enhancement projects
  
• A minimum of 3 years’ experience interacting with vendors and third parties effectively to meet commitments and milestones.
  
• A minimum of 1 year testing experience
  
• Must be able to travel to Nashville, Tennessee 50% of the time, post COVID-19 restrictions
  
  
   
  

Preferred Skills:

• Experience interpreting complex eligibility determination rules, policy, and processes
  
• Experience in the health and human services related industry
  
• Ability to work independently and manage work to a defined schedule
  
• Strong written and verbal communication skills
  
• Team player and a consistent, dependable performer with an excellent work ethic, flexible “can-do” attitude, and a results-driven commitment to success
  
• Ability to apply industry best practices and future state/federal mandates to existing systems
  
• Excels at using quantitative data to drive recommendations and decisions
  
  
   
  

For Colorado Candidates


In compliance with the Colorado Equal Pay Transparency Rules, NTT DATA provides a reasonable range of compensation for roles that may be hired in Colorado. For a candidate in the state of Colorado only, the starting pay range for this role is 72,700 to 85,000. Actual compensation will depend on a number of factors, including actual work location, relevant experience (internal or external), technical skills, and other qualifications.


This position is eligible for company benefits including medical, dental, and vision insurance with an employer contribution, flexible spending or health savings account, life and AD&D insurance, short and long-term disability coverage, paid time off, employee assistance, participation in a 401k program with company match, and additional voluntary or legally-required benefits.


About NTT DATA Services


NTT DATA Services is a global business and IT services provider specializing in digital, cloud and automation across a comprehensive portfolio of consulting, applications, infrastructure and business process services. We are part of the NTT family of companies, a partner to 85 % of the Fortune 100.


NTT DATA Services is an equal opportunity employer and considers all applicants without regarding to race, color, religion, citizenship, national origin, ancestry, age, sex, sexual orientation, gender identity, genetic information, physical or mental disability, veteran or marital status, or any other characteristic protected by law. We are committed to creating a diverse and inclusive environment for all employees. If you need assistance or an accommodation due to a disability, please inform your recruiter so that we may connect you with the appropriate team.

Clipped from: https://www.careerbuilder.com/job/JMD8862263F12U36UT3?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

JOB SUMMARY: Responsible for oversight of all Provider services and network development functionality specific to the plan’s Medicaid product. Responsible for network adequacy activities, provider contracting, relationship development, provider education and communications and activities specific to operations as directed by the Senior Manager, Provider Network Administration.KEY RESPONSIBILITIES: Build and maintain network including recruitment of providers as needed to attain network expansion and adequacy targets. Develop network adequacy goals and conduct ongoing monitoring to ensure network adequacy compliance with standards established by the State.Participate in the design of value-based reimbursement models in support of business strategies. Participate in development of quality and utilization metrics to achieve healthy outcomes for Medicaid members. Guides, under the direction of the Senior Manager, Provider Network Administration, provider contracting with health systems, hospitals, physician groups, individual practitioners, ancillary services, and community based social services agencies. Facilitate the development of statewide network. Ensure, to the extent possible, consistency with all other product strategies. Ensure contracts meet all regulatory and accreditation requirements.Develop and maintain relationships with health systems and key provider groups leadership. Develop and maintain relationships with community and social service agencies onboarded to assist with Social Determinants of Health (SDOH). Guide provider services representatives to ensure resolution of escalated provider issues. Oversee the planning of plan sponsored health events.Develop and maintain provider manual. Develop and maintain provider education and communication materials. Collaborate with development of plan employee education materials. Assist plan provider relations staff with educating providers on Medicaid product, policies and procedures, and programs.Participate in product strategy development. Develop and recommend updates to policies and procedures. Review member complaints against providers to identify trends. Initiative and program planning. Resource to departments for problem solving provider related issues and contract interpretation. Review and analysis of applicable reports. Attends Medicaid specific operations / leadership meetings. Additional responsibilities as assigned by leadershipQUALIFICATIONS: Ability to process and understand complex information. Ability to organize and oversee multiple complex tasks/projects to completion. Ability to coordinate resources in an effective, cost-efficient manner. Excellent communication and interpersonal skills. Ability to interpret and communicate detailed technical and financial information. Demonstrated knowledge of physician and hospital capitation reimbursement methodologies. Familiarity with healthcare and managed care business operations environments. Strong familiarity with managed care terminology. Proficiency with software systems including Amisys, Microsoft Word and Excel. Ability to converse and write fluently in English. EDUCATION/EXPERIENCE: Bachelor’s degree plus 3 years work related experience. Managerial / Supervisory experience preferred. Demonstrate, through past performance and progressive increases in responsibility, the ability to accomplish goals. Excellent oral presentation and writing skills. Previous physician/hospital contracting and reimbursement development experience. Familiarity with providers and provider issues in a managed care environment. Previous claims software experience, preferably Amisys.CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national originOther details Pay Type Salary Apply Now

Recommended Skills

• Problem Solving
  
• Management
  
• Leadership
  
• Human Resources
  
• Training
  
• Training And Development
  

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Clipped from: https://www.linkedin.com/jobs/view/nurse-medical-management-i-inpatient-medicaid-at-elevance-health-3524669881/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Description

 
 

Nurse Medical Management I – InPatient Medicaid (JR58761)

 
 

Work Hours: 8am – 5pm, Pacific Standard Time.

 
 

Location: Remote. Must be willing to work from the local office as needed.

 
 

Primary Duties May Include, But Are Not Limited To

 
 

The Nurse Medical Management l is responsible to collaborate 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 inpatient admissions, outpatient services, focused surgical 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, programs or community resources. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied.

 
 

• Conducts pre-certification, continued stay review, care coordination, or discharge planning 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.
  
• Collaborates with providers to assess member’s needs for early identification of and proactive planning for discharge planning.
  
• 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.
  

 
 

Minimum Requirements

 
 

• Current active unrestricted RN license to practice as a health professional within the scope of practice in the state of residence.
  
• Minimum 2 years acute care clinical experience.
  
• 3 years InPatient experience.
  
• Must be willing to work from the local office as needed.
  
• Must work 8am – 5pm, Monday – Friday, Pacific Time.
  

 
 

Preferred Qualifications

 
 

• Utilization Management / Review preferred.
  
• Health Insurance experience.
  
• Knowledge of Medicaid benefits preferred.
  

 
 

Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

 
 

Be part of an Extraordinary Team

 
 

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. A Fortune 20 company with a longstanding history in the healthcare industry, we are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

 
 

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 in certain patient/member-facing roles 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 2022, has been ranked for five years running as one of the 2023 World’s Most Admired Companies by Fortune magazine, and is a growing Top 20 Fortune 500 Company. 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.

 
 

Be part of an Extraordinary Team

 
 

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. A Fortune 20 company with a longstanding history in the healthcare industry, we are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

 
 

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 in certain patient/member-facing roles 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 2022, has been ranked for five years running as one of the 2023 World’s Most Admired Companies by Fortune magazine, and is a growing Top 20 Fortune 500 Company. 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.