Category: MM Curator

Clipped from: http://federalgovernmentjobs.us/jobs/Deputy-Center-Director-Oversight-and-Enforcement-Policy-Center-For-Program-Integrity-709433400.html?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Summary

This position is located in the Center for Program Integrity, Centers for Medicare and Medicaid Services (CMS).

As the Deputy Center Director (Oversight and Enforcement Policy), you will provide executive leadership and direction in developing and implementing Medicare, Medicaid, and Marketplace program integrity programs, strategic direction for CMS, the states, and law enforcement partners, and all actions CPI takes to hold providers and suppliers responsible for fraud, waste, and abuse.”

Overview

• Open & closing dates
  

03/01/2023 to 04/01/2023

• Salary
  

$141,022 – $212,100 per year

• Pay scale & grade
  

ES 00

• Locations
  

1 vacancy in the following locations:

• Washington
  
• Baltimore, MD
  
• Remote job
  

No

• Telework eligible
  

Yes—as determined by the agency policy.

• Travel Required
  

Occasional travel – You may be expected to travel for this position.

• Relocation expenses reimbursed
  

No

• Appointment type
  

Permanent –

• Work schedule
  

Full-time –

• Service
  

Senior Executive

• Promotion potential
  

None

• Job family (Series)
  

0340 Program Management

• Supervisory status
  

Yes

• Security clearance
  

Not Required

• Drug test
  

Yes

• Position sensitivity and risk
  

Critical-Sensitive (CS)/High Risk

• Trust determination process
  

Suitability/Fitness

• Announcement number
  

HHS-CMS-ES-2023-11855155

• Control number
  

709433400

This job is open to

• Senior executives
  

Those who meet the five Executive Core Qualifications (ECQs).

• The public
  

U.S. Citizens, Nationals or those who owe allegiance to the U.S.

Clarification from the agency

All groups of qualified individuals

Duties

• Integrates program integrity activities and contracting into a strategic framework targeting the highest risk areas and health system issues focusing on preventing fraud, waste, and abuse.
  
• Develops and implements innovative program integrity initiatives.
  
• Provides executive leadership and direction in developing and implementing Medicare, Medicaid, and Marketplace program integrity programs and provides strategic direction for CMS, the states, and law enforcement partners.
  
• Directs the development of Medicare, Medicaid, and Marketplace program integrity strategy and tactics for fee-for-service and managed care financing.
  
• Plans and develops methods to monitor program integrity efforts, including provider enrollment, administration, and coordination of CMS’s efforts to curb fraud and abuse in the Medicare, Medicaid, and Marketplace programs.
  
• Manages all facets of program integrity functions for Medicare Administrative Contractors and Medicare Integrity Program contractors and manages all Medicare and Medicaid program integrity enforcement activities.
  

Requirements Conditions of Employment

• U.S. Citizenship required.
  
• Background and/or Security Investigation required.
  
• One year SES probationary period required.
  
• The Ethics in Government Act, PL 95-521 requires the applicant selected for this position to submit a financial disclosure statement, SF-278, prior to assuming the SES position, annually, and upon termination of employment.
  
• Status applicants must submit a copy of their most recent SF-50, Notification of Personnel Action, which verifies status.
  
• All initial appointments to an SES position are contingent on approval from OPM’s Qualifications Review Board unless the selectee has successfully participated in an OPM approved SES Candidate Development Program.
  
• All male applicants born after December 31, 1959, must have registered for the selective service. You will be required to sign a statement certifying his registration, or the applicant must demonstrate exempt status under the Selective Service Law.
  
• Only experience obtained by the closing date of this announcement will be considered.
  

Qualifications

All competitive candidates for SES positions with the Federal Government must demonstrate leadership experience indicative of senior executive level management capability. To meet the minimum qualification requirements for this position, you must show in your resume that you possess the Fundamental Competencies, five Executive Core Qualifications, and the Professional/Technical Qualifications listed below. Evidence of this experience must be incorporated into your five page resume. Separate narratives for the Executive Core Qualifications and/or Professional/Technical Qualifications will not be accepted or considered. Typically, experience of this nature is gained at or above the GS-15 grade level in the Federal service, or its equivalent with state or local government, the private sector, or nongovernmental organizations.


Fundamental Competencies:
Interpersonal Skills, Oral Communication, Integrity/Honesty, Written Communication, Continual Learning, and Public Service Motivation.


Executive Core Qualifications (ECQs)

1. Leading Change: The ability to bring about strategic change, both within and outside the organization, to meet organizational goals. Inherent to this ECQ is the ability to establish an organizational vision and to implement it in a continuously changing environment.
   
2. Leading People: The ability to lead people toward meeting the organization’s vision, mission, and goals. Inherent to this ECQ is the ability to provide an inclusive workplace that fosters the development of others, facilitates cooperation and teamwork, and supports constructive resolution of conflicts.
   
3. Results Driven: The ability to meet organizational goals and customer expectations. Inherent to this ECQ is the ability to make decisions that produce high-quality results by applying technical knowledge, analyzing problems, and calculating risks.
   
4. Business Acumen: The ability to manage human, financial, and information resources strategically.
   
5. Building Coalitions: The ability to build coalitions internally and with other Federal agencies, State and local governments, nonprofit and private sector organizations, foreign governments, or international organizations to achieve common goals.
   

Professional/Technical Qualifications (PTQs)


This position also requires that you possess PTQs that represent knowledge, skills, and abilities essential for success in this role. The following PTQs must be evident in your resume.

1. Demonstrated knowledge and experience in managing health care delivery, program integrity, utilization management, or public health program functions within a large-scale health plan/program, including the critical social, political, and economic forces that affect them.
   
2. Comprehensive knowledge of laws, policies, and regulations that apply to the administration of health care delivery and program integrity and a demonstrated ability to use this knowledge and associated metrics to assess and improve program effectiveness, management processes, and systems to achieve organizational priorities and results.
   
3. Demonstrated experience, in a senior leadership position, dealing and negotiating with a wide range of senior level officials in various government agencies, law enforcement organizations, and/or public and private organizations on complex and controversial issues concerning health care programs, including the protection of the integrity of these programs.
   

It is STRONGLY recommended that you visit the following Office of Personnel Management (OPM) webpage for more information regarding the Fundamental Competencies and ECQs.

https://www.opm.gov/policy-data-oversight/senior-executive-service/executive-core-qualifications/#url=Overview

If selected, you will be required to complete an ECQ package by drafting narratives for each of the ECQs for submission and certification by an OPM Qualifications Review Board (QRB) in order to be placed in this position. If you are currently serving in a career SES appointment, are eligible for reinstatement into the SES, or have successfully completed an SES Candidate Development Program approved by the Office of Personnel Management (OPM), you will not need to draft the ECQs.

Education

This job does not have an education qualification requirement.

Additional information

Salary for SES positions varies depending on qualifications. The annual salary range is found at the top of this announcement. The selectee for this position may be eligible for annual performance bonuses and performance-based pay adjustments.


Veteran’s Preference does not apply to the SES.
Federal agencies may request information regarding the vaccination status of selected applicants for the purposes of implementing other workplace safety protocols, such as protocols related to masking, physical distancing, testing, travel, and quarantine.


Workplace Flexibility at CMS: CMS offers flexible working arrangements and allows employees the opportunity to participate in telework combined with alternative work schedules at the manager’s discretion. This position may be authorized for telework. Telework eligibility will be discussed during the interview process.


To ensure compliance with an applicable preliminary nationwide injunction, which may be supplemented, modified, or vacated, depending on the course of ongoing litigation, the Federal Government will take no action to implement or enforce Executive Order 14043 Requiring Coronavirus Disease 2019 Vaccination for Federal Employees. Therefore, to the extent a federal job announcement includes the requirement to be fully vaccinated against COVID-19 pursuant to Executive Order 14043, that requirement does not currently apply. Positions with vaccination requirements under authority(ies) separate and distinct from Executive Order 14043 will be clearly identified. HHS may continue to require documentation of proof of vaccination to ensure compliance with those policies. Health and safety protocols remain in effect, in accordance with CDC guidance and the Safer Federal Workforce Task force. Consistent with current guidance, workplace safety protocols will no longer vary based on vaccination status or otherwise depend on the availability of vaccination information. Therefore, to the extent a job announcement states that HHS may request information regarding the vaccination status of selected applicants for the purposes of implementing workplace safety protocols, this statement does not currently apply.

Benefits

A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.

Review our benefits

Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.

How You Will Be Evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

We use a multi-step process to evaluate and refer applicants:

1. Minimum requirements: Your application must show that you meet all requirements, including the education and/or experience required for this position. You may be found ‘not qualified’ if you do not possess the minimum competencies required for the position. If your application is incomplete, we may rate you as ineligible.
   
2. Rating: A panel of Senior Executives will review your application and evaluate your qualification for this position based on the information in your application. Your application will be rated, based on the extent and quality of your experience, education, and training relevant to the duties of this position. Interviews will be at the discretion of the panel and/or selection official.
   
3. Referral: If you are among the top qualified candidates, your application will be referred to a selection official for consideration and possible interview.
   

Benefits

A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.

Review our benefits

Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.

Required Documents

As a new or existing federal employee, you and your family may have access to a range of benefits. Your benefits depend on the type of position you have – whether you’re a permanent, part-time, temporary or an intermittent employee. You may be eligible for the following benefits, however, check with your agency to make sure you’re eligible under their policies.

All applicants are required to submit and/or complete the following documents to be considered for the position:

1. Resume that contains your full name, address and phone number, and does not exceed the five page limit;
   
2. Cover Letter (optional);
   
3. Online Assessment Questionnaire. To preview the assessment questionnaire, click here: https://apply.usastaffing.gov/ViewQuestionnaire/11855155
   

NOTE: THE USAJOBS RESUME TEMPLATE MAY RESULT IN A RESUME BEING LONGER THAN FIVE PAGES. PLEASE VERIFY PAGE LENGTH BEFORE SUBMISSION OF APPLICATION.


Applicants who are currently, or were previously, Federal employees must also submit:

1. An SF-50 showing your current or former civil service status; and
   
2. Proof of OPM Qualifications Review Board certification (OPM-approved SES Candidate Development Program graduates), if applicable.
   

NOTE: Documents submitted that are not listed in the Required Documents section of this announcement will not be considered or forwarded to the rating panel or selecting official.

How to Apply

The application process used to recruit for this position is the RESUME BASED method. Although applicants cannot address the ECQs or PTQs separately, evidence of each must be clearly demonstrated in the five page resume and throughout the rest of the application package.


To be considered for this position, you must submit a complete application no later than 11:59 PM (Eastern Time) on the closing date of the announcement – 04/01/2023. If you fail to submit a complete application prior to the closing time, the application system will not allow you to finish. Requests for extensions will not be granted, so please begin the application process with enough time to finish before the deadline.


ALL APPLICANTS (including Commissioned Corps Officers): You must submit a resume (five-page maximum – resumes that exceed the five-page limit will not be considered). You may also submit an optional cover letter. Separate written narratives addressing the ECQs and PTQs will not be considered.


You must complete the online assessment questions. If your resume does not support the responses in your questionnaire, you may be rated “ineligible.” We recommend that your resume emphasize your level of responsibilities, the scope and complexity of the programs managed, and your program accomplishments, including the results of your actions.


Your five page resume should include the following:

1. Job Information (Announcement number and title of job for which you are applying)
   
2. Personal Information (Full name, mailing address, work and home phone number and email addresses)
   
3. Education (College/University name, city and state, major, type and year of degree)
   
4. Work Experience (Job title (including series and grade, if Federal employment, duties and accomplishments, employer’s name and address, start and end dates (month and year), hours per week, and salary)
   
5. Evidence of experience which addresses the five ECQs and the PTQs.
   
6. Other qualifications (Job-related training courses (title and year), skills, certifications and licenses, honors, awards, and special accomplishments).
   

It is important that your resume be complete and thorough. Please be sure to include and address all ECQs and PTQs in your resume. A sample five-page resume that incorporates the ECQs can be found in OPM’s Guide to Senior Executive Service Qualifications: https://www.opm.gov/policy-data-oversight/senior-executive-service/reference-materials/guidetosesquals_2012.pdf
Steps to submit a complete application:

1. You must have a USAJobs account and be logged in.
   
2. Once you are logged in and all of your application materials are ready, click the “Apply” button.
   
3. You must respond to all application assessment questions, carefully following the instructions provided. To preview the questions, click here: https://apply.usastaffing.gov/ViewQuestionnaire/11855155
   
4. You will then be asked to upload your resume and optional cover letter. Additional documentation not listed in the Required Documents will not be considered.
   

Agency contact information Kathy Vaughn

Phone

410-786-1050

Email

Katherine.vaughn@cms.hhs.gov

Address

Center for Program Integrity
7500 Security Blvd
Woodlawn, MD 21244
US

Learn more about this agency

Next steps

You will receive an email informing you of the receipt of your application. Applicants who are determined to be highly qualified by the SES rating panel will be referred to the selecting official for further consideration and possible interview, at which time you will be contacted. All applicants will be notified of the outcome of their applications once a final selection is made.

Required Documents

All applicants are required to submit and/or complete the following documents to be considered for the position:

1. Resume that contains your full name, address and phone number, and does not exceed the five page limit;
   
2. Cover Letter (optional);
   
3. Online Assessment Questionnaire. To preview the assessment questionnaire, click here: https://apply.usastaffing.gov/ViewQuestionnaire/11855155
   

NOTE: THE USAJOBS RESUME TEMPLATE MAY RESULT IN A RESUME BEING LONGER THAN FIVE PAGES. PLEASE VERIFY PAGE LENGTH BEFORE SUBMISSION OF APPLICATION.


Applicants who are currently, or were previously, Federal employees must also submit:

1. An SF-50 showing your current or former civil service status; and
   
2. Proof of OPM Qualifications Review Board certification (OPM-approved SES Candidate Development Program graduates), if applicable.
   

NOTE: Documents submitted that are not listed in the Required Documents section of this announcement will not be considered or forwarded to the rating panel or selecting official.

How to Apply

The application process used to recruit for this position is the RESUME BASED method. Although applicants cannot address the ECQs or PTQs separately, evidence of each must be clearly demonstrated in the five page resume and throughout the rest of the application package.


To be considered for this position, you must submit a complete application no later than 11:59 PM (Eastern Time) on the closing date of the announcement – 04/01/2023. If you fail to submit a complete application prior to the closing time, the application system will not allow you to finish. Requests for extensions will not be granted, so please begin the application process with enough time to finish before the deadline.


ALL APPLICANTS (including Commissioned Corps Officers): You must submit a resume (five-page maximum – resumes that exceed the five-page limit will not be considered). You may also submit an optional cover letter. Separate written narratives addressing the ECQs and PTQs will not be considered.


You must complete the online assessment questions. If your resume does not support the responses in your questionnaire, you may be rated “ineligible.” We recommend that your resume emphasize your level of responsibilities, the scope and complexity of the programs managed, and your program accomplishments, including the results of your actions.


Your five page resume should include the following:

1. Job Information (Announcement number and title of job for which you are applying)
   
2. Personal Information (Full name, mailing address, work and home phone number and email addresses)
   
3. Education (College/University name, city and state, major, type and year of degree)
   
4. Work Experience (Job title (including series and grade, if Federal employment, duties and accomplishments, employer’s name and address, start and end dates (month and year), hours per week, and salary)
   
5. Evidence of experience which addresses the five ECQs and the PTQs.
   
6. Other qualifications (Job-related training courses (title and year), skills, certifications and licenses, honors, awards, and special accomplishments).
   

It is important that your resume be complete and thorough. Please be sure to include and address all ECQs and PTQs in your resume. A sample five-page resume that incorporates the ECQs can be found in OPM’s Guide to Senior Executive Service Qualifications: https://www.opm.gov/policy-data-oversight/senior-executive-service/reference-materials/guidetosesquals_2012.pdf
Steps to submit a complete application:

1. You must have a USAJobs account and be logged in.
   
2. Once you are logged in and all of your application materials are ready, click the “Apply” button.
   
3. You must respond to all application assessment questions, carefully following the instructions provided. To preview the questions, click here: https://apply.usastaffing.gov/ViewQuestionnaire/11855155
   
4. You will then be asked to upload your resume and optional cover letter. Additional documentation not listed in the Required Documents will not be considered.
   

Agency contact information Kathy Vaughn

Phone

410-786-1050

Email

Katherine.vaughn@cms.hhs.gov

Address

Center for Program Integrity
7500 Security Blvd
Woodlawn, MD 21244
US

Learn more about this agency

Next steps

You will receive an email informing you of the receipt of your application. Applicants who are determined to be highly qualified by the SES rating panel will be referred to the selecting official for further consideration and possible interview, at which time you will be contacted. All applicants will be notified of the outcome of their applications once a final selection is made.

Clipped from: https://www.adzuna.com/details/3954508927?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Salary: Location: Company: Hours:

 
 

Qlarant is a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient delivery of health care and human services programs. We have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Qlarant is also a national leader in fighting fraud, waste and abuse for large organizations across the country. In addition, our Foundation provides grant opportunities to those with programs for under-served communities.

Are you skilled in reviewing Medicaid claims and source records? Do you have a track record of exceeding expectations, meeting deadlines and handling multiple assignments? If that sounds like you, Qlarant has the perfect opportunity! We have an immediate opening for a Healthcare Fraud Investigator II on our UPIC SW Medicaid investigations team. This position could be based in our Dallas or Easton, MD offices or home-based in most states in the continental US. Qlarant offers an excellent benefits package that includes healthcare, two retirement plans and a generous leave program.

As a Healthcare Fraud Investigator II working on our Unified Program Integrity Contractor (UPIC) team for the Southwest Jurisdiction, you can contribute to our efforts to make a positive difference in the future of the Medicare and Medicaid programs. Our UPIC Southwest team identifies and investigates fraud, waste and abuse in the Medicare and Medicaid programs covering 7 states.

This is a mid-level professional position that performs evaluations of investigations and makes field level judgments of potential Medicaid and Medicare fraud, waste, and abuse that meet established criteria for referral to law enforcement or administrative action.

Essential Duties and Responsibilities include the following. Other duties may be assigned

• Utilizes leads provided by the team and referrals from government and private agencies, works with the team to prioritize complaints for investigation, and then investigates, conducts interviews and reviews information to make potential fraud determination.
  
• Determines investigation or case appropriateness of fraud, waste and abuse issues in accordance with pre-established criteria.
  
• Based on contract requirements, may refer potential adverse decisions to the Lead Investigator/Manager/Medical Director or designee.
  
• Conducts interviews of witnesses, informants, and subject area experts and targets of investigations.
  
• Identifies, collects, preserves, analyzes and summarizes evidence, examines records, verifies authenticity of documents, and may provide information to support the preparation of attestations/referrals
  
• Drafts investigation reports, evaluates investigation reports, and promotes effective and efficient investigations.
  
• Initiates and maintains communications with law enforcement and appropriate regulatory agencies including presenting or assisting with presenting investigation or case findings for their consideration to further investigate, prosecute, or seek other appropriate regulatory or administrative remedies.
  
• Testifies at various legal proceedings as necessary.
  
• Identifies opportunities to improve processes and procedures.
  
• Has the responsibility and authority to perform their job and provide customer satisfaction.
  

Supervisory Responsibilities: This job has no supervisory responsibilities.

Required Skills
 

• Ability to work independently with minimal supervision
  
• Ability to communicate effectively with all members of the team to which he/she is assigned
  
• Ability to grasp and adapt to changes in procedure and process
  
• Ability to effectively resolve complex issues
  
• Ability to mentor other associates
  
• Additional required skills include:
  

 
 

• Report writing and documentation
  
• Federal and State Policy research
  
• Reviewing Medicaid claims and source records
  
• Proficiency in Microsoft Excel and Word
  
• Attention to detail
  

Required Experience
 

• Bachelor’s Degree and two years’ experience in investigations/fraud detection or healthcare programs required. Equivalent education and experience may be combined.
  
• Experience reviewing Medicaid claims or exposure to Medicaid (administrative, investigative, data, or otherwise) is stronly preferred.
  
• Prior successful experience with CMS and OIG/FBI or similar agencies preferred.
  
• Certification in an applicable program such as Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator Certification or successful completion of a law enforcement academy preferred.
  

Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.

 
 

• Ability to work independently with minimal supervision
  
• Ability to communicate effectively with all members of the team to which he/she is assigned
  
• Ability to grasp and adapt to changes in procedure and process
  
• Ability to effectively resolve complex issues
  
• Ability to mentor other associates
  
• Additional required skills include:
  

 
 

• Report writing and documentation
  
• Federal and State Policy research
  
• Reviewing Medicaid claims and source records
  
• Proficiency in Microsoft Excel and Word
  
• Attention to detail
  

 
 

• Bachelor’s Degree and two years’ experience in investigations/fraud detection or healthcare programs required. Equivalent education and experience may be combined.
  
• Experience reviewing Medicaid claims or exposure to Medicaid (administrative, investigative, data, or otherwise) is stronly preferred.
  
• Prior successful experience with CMS and OIG/FBI or similar agencies preferred.
  
• Certification in an applicable program such as Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator Certification or successful completion of a law enforcement academy preferred.
  

Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.

Clipped from: https://www.linkedin.com/jobs/view/lead-director-network-provider-relations-michigan-medicaid-remote-at-cvs-health-3505730229/?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: $ 227,000

 
 

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://www.ziprecruiter.com/c/State-of-Maine/Job/Medicaid-Program-Analyst/-in-Augusta,ME?jid=ec049c3f58aef348&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Department of Health and Human Services (DHHS)
Management Analyst II
Opening Date: March 1, 2023
Closing Date: March 15, 2023
Job Class Code: 0393
Grade: 04-24 (Pro/Tech)
Salary: $47,340.80 – $63,814.40/year
Position Number: 02000-4000

Core Responsibilities:

The MaineCare Program Analyst helps ensure sustainable, long-term operational efficiency for programs within MaineCare, including but not limited to Alternative Payment Models (APMs) like Accountable Communities and Primary Care Plus. An APM is a health care payment method that uses financial incentives to raise the quality of care, improve health outcomes, and lower costs for patients, purchasers, payers, and/or providers. IAlong with other strategies, APMs are important for advancing policies that improve the quality and value of health care.

This position is responsible for gathering and organizing information, researching best practices, developing materials and reportsand documenting these processes to enhance operational efficiency. Some data analysis is required in this position, as well as the ability to translate information into recommendations for organizational and system changes.

Additionally, the successful candidate will engage with contracted vendors and collaborate with other MaineCare units around data reporting and data management in support of MaineCare members, staff, and health care providers.

The Program Analyst will work collaboratively with staff across DHHS as well as external partners, including health care providers, community-based organizations, and public health entities. The successful candidate will be invigorated by team-based environments, intentional collaboration, and thoughtful communication.

Work is performed under limited supervision. Some in-state travel required.

Minimum Qualifications:

Eight (8) years of education, training, and/or experience analyzing, evaluating, and/or developing improvements to organizational and/or managerial systems, programs, and practices.

Preferred experience includes:
 

• Experience with and knowledge of the Medicaid program and/or other health and human services programs serving low-income or other at-risk populations
  
• Lived experience with Medicaid and/or other health-related social needs common to individuals and families receiving Medicaid coverage
  

The background of well-qualified candidates will demonstrate the following competencies:
 

1. Ability to think critically and strategically about program operations and their impact on reaching goals such as improved health outcomes or reduced health care costs.
   
2. Basic project management skills, including development and implementation of workplans, quality assurance processes, and methods and techniques used in establishing work standards.
   
3. Knowledge of methods and techniques of analysis, work simplification, and data management used to organize teams and work.
   
4. Minimum of basic competency with statistical methods, especially those used in program planning and monitoring.
   
5. Knowledge of data collection methods, including the ability to gather, assemble, analyze, and devise valid conclusions from different sources of information ranging from general internet-based research on national health care models to analyzing excel data sets for program trends.
   
6. Ability to effectively use verbal and written communication as tools for initiating and completing work.
   

Agency information:

The Department of Health and Human Services (DHHS) provides supportive, preventive, protective, public health and intervention services that help families and individuals meet their needs. DHHS strives to provide these programs and services while respecting the rights and preferences of individuals and families. The Office of MaineCare Services (OMS) within DHHS administers the state’s Medicaid program, which provides health insurance coverage for low-income families, adults and children so they can access the important health care services they need to be healthy and be a part of the community through work, caring for family, going to school, and more. OMS works collaboratively within DHHS, with other Departments and the Office of the Governor, with MaineCare members, with providers, and with other health care purchasers on statewide healthcare improvement initiatives. OMS is committed to advancing health equity efforts to improve access to care and health outcomes for all low-income Mainers. OMS provides benefit coverage and supports the services that operate in alignment with Department goals, federal mandates and State policy. OMS also provides oversight necessary to ensure accountability and efficient and effective administration.

This position is located within the OMS Delivery System Reform Unit (DSRU) and reports to the DSRU Quality Manager. The DSRU collaborates with internal and external stakeholders to incorporate clinical, social, fiscal, and operational considerations into the design and implementation of new MaineCare initiatives that seek to improve outcomes through changes to health care operations, delivery, and/or payment models. This team focuses on the design and implementation stages of large and small initiatives and works collaboratively with other MaineCare units to ultimately transition these initiatives into our ongoing operations.

Application Information:

Please submit all documents or files in a PDF or Word format.

For additional information about this position, please contact Charyl Malik at (207) 624-4043.

To apply, please upload a resume and cover letter with your application.

To request a paper application, please contact Ashley.Smith@Maine.gov .

Benefits

No matter where you work across Maine state government, you find employees who embody our state motto-“Dirigo” or “I lead”-as they provide essential services to Mainers every day. We believe in supporting our workforce’s health and wellbeing with a valuable total compensation package, including:
 

• Work-Life Balance – Rest is essential. Take time for yourself using 13 paid holidays, 12 days of sick leave, and 3+ weeks of vacation leave annually. Vacation leave accrual increases with years of service, and overtime-exempt employees receive personal leave.
  
• Health Insurance Coverage – The State of Maine pays 85%-100% of employee-only premiums ($10,150.80-$11,942.16 annual value), depending on salary. Use this chart to find the premium costs for you and your family, including the percentage of dependent coverage paid by the State.
  

 
 

• Health Insurance Premium Credit – Participation decreases employee-only premiums by 5%. Visit the Office of Employee Health and Wellness for more information about program requirements.
  

 
 

• Dental Insurance – The State of Maine pays 100% of employee-only dental premiums ($350.40 annual value).
  

 
 

• Retirement Plan – The State of Maine contributes 13.16%of pay to the Maine Public Employees Retirement System (MainePERS), on behalf of the employee.
  
• Gym Membership Reimbursement – Improve overall health with regular exercise and receive up to $40 per month to offset this expense.
  
• Health and Dependent Care Flexible Spending Accounts – Set aside money pre-tax to help pay for out-of-pocket health care expenses and/or daycare expenses.
  
• Public Service Student Loan Forgiveness – The State of Maine is a qualified employer for this federal program. For more information, visit the Federal Student Aid office.
  
• Living Resources Program – Navigate challenging work and life situations with our employee assistance program.
  

 
 

• Parental leave is one of the most important benefits for any working parent. All employees who are welcoming a child-including fathers and adoptive parents-receive four weeks of fully paid parental leave. Additional, unpaid leave may also be available, under the Family and Medical Leave Act.
  
• Voluntary Deferred Compensation – Save additional pre-tax funds for retirement in a MaineSaves 457(b) account through payroll deductions.
  
• Learn about additional wellness benefits for State employees from the Office of Employee Health and Wellness.
  

There’s a job and then there’s purposeful, transformative work. Our aim is to create a workplace where you can learn, grow, and continuously refine your skills. Applicants demonstrate job requirements in differing ways, and we appreciate that many skills and backgrounds can make people successful in this role.

As an Equal Opportunity employer, Maine State Government embraces a culture of respect and awareness. We are committed to creating a strong sense of belonging for all team members, and our process ensures an inclusive environment to applicants of all backgrounds including diverse race, color, sex, sexual orientation or gender identity, physical or mental disability, religion, age, ancestry, national origin, familial status or genetics.

If you’re looking for a great next step, and want to feel good about what you do, we’d love to hear from you. Please note reasonable accommodations are provided to qualified individuals with disabilities upon request.

Thinking about applying?

Research shows that people from historically excluded communities tend to apply to jobs only when they check every box in the posting. If you’re currently reading this and hesitating to apply for that reason, we encourage you to go for it! Let us know how your lived experience and passion set you apart.

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Position Description:
 

About Mathematica:


Mathematica applies expertise at the intersection of analytics, technology, 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. Learn more about our benefits here: https://www.mathematica.org/career-opportunities/benefits-at-a-glance 

One of Mathematica’s core values is a deep commitment to diversity, equity, and inclusion. Our research is more robust because it is informed by a variety of diverse perspectives, and our mission to improve societal well-being is strengthened by a greater understanding of issues and challenges facing the populations we serve. Mathematica’s ongoing commitment to diversity and inclusion is woven into our everyday actions, policies, and practices. We are dedicated to maintaining a work environment in which everyone is treated with respect and dignity. 

About the opportunity: 

Mathematica is searching for self-motivated professionals with a passion for solving clients’ pressing problems with backgrounds in program operations and health care delivery, and a strong interest in our Medicaid project area. Managing consultants often work on or lead more than one project at a time and are matched with projects that align with their interests and skills. In particular, we are looking for individuals who can support current and emerging work across any number of areas related to monitoring and improving Medicaid programs such as: Medicaid managed care programs including payment arrangements and in lieu of services, behavioral health delivery, maternal and child health, equity, Medicaid payment mechanisms including UPL/DSH and state directed payments, value-based purchasing and alternative payment models, long-term services and supports, measures of delivery and quality of services for beneficiaries, and outcomes of innovative programs and policies. It is ideal for a candidate to have past experience at the state, local or provider level in health care operations relevant to Medicaid. 

Managing consultants participate in and lead a range of tasks at Mathematica, from overseeing teams or managing projects and driving to solutions for some of our clients most challenging problems. While the duties of the position vary depending on project assignments, most managing consultants serve in roles that require a blend of policy and operational expertise and management skills. This may include:

• Serving as task leaders, deputy project directors, or project directors on complex, fast-paced projects focused on Medicaid policy, oversight, and program operations
  
• Collaborating with federal, state, and other clients and entities to develop and implement quality improvement strategies or technical assistance plans based on available data and subject matter expertise
  
• Planning and executing of webinars or small group discussions with government clients, healthcare payers, and/or other entities and individuals
  
• Managing diverse perspectives and thinking creatively to design solutions that meet client needs
  
• Authoring memos, standard operating procedures, data dictionaries, implementation guides, webinar slides, and other technical assistance tools to facilitate program improvement
  
• Providing the energy, direction, organization, and quality control needed to help keep projects on time and on budget and to facilitate communications across and between internal and external stakeholders
  

Position Requirements:
 

• Master’s degree in public policy, public administration, public health, healthcare administration, business, or a related field; or equivalent experience
  
• Five or more years of experience managing complex projects or tasks related to healthcare or health policy.
  
• Experience working at or with a local, state or federal agency, a foundation, a healthcare provider, a Medicaid managed care plan or another policy research firm is highly desirable.
  
• Demonstrated ability to lead activities, manage tasks through the project lifecycle, and coordinate the work of multidisciplinary teams to deliver high-quality work to our clients on time and budget
  
• Strong analytic skills and ability to think critically about issues relating to management, such as financial analysis, as well as policy implementation and program operations.
  
• Excellent written and oral communication skills, including an ability to explain observations and findings to diverse stakeholder audiences including program administrators and policymakers
  
• Strong organizational skills and high level of attention to detail as well as the flexibility to manage multiple priorities, sometimes simultaneously, under deadlines
  
• Strong mentorship skills to mentor several junior staff members
  

Depending on experience, candidates may be considered at the Senior Managing Consultant level as well. 

Please submit a cover letter, CV and work product that demonstrates your analytic abilities as well as your understanding of complex policy-related challenges facing the healthcare system.

This position offers an anticipated annual base salary range of $90,000 – $125,000. This position may be eligible for an annual discretionary bonus based on individual and company performance. 

In accordance with Executive Order 14042 and its implementing guidelines, all Mathematica employees must provide documentation that they have been fully vaccinated against COVID-19 or obtain an accommodation through Human Resources by providing documentation from a licensed health care provider that they are unable to be vaccinated against COVID-19 because of a disability (which would include medical conditions) or provide an attestation that they are entitled to an accommodation because of a sincerely held religious belief, practice, or observance.

Available locations:  Princeton, NJ; Washington, DC; Cambridge, MA; Chicago, IL; Ann Arbor, MI; Oakland, CA; Seattle, WA; Remote 

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

Clipped from: https://www.theladders.com/job/vp-care-management-medicaid-cvshealth-hartford-ct_62356204?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

2d ago

compensation:

$250K — $500K+*

industry:

Healthcare

specialty:

Allied Health Professionals, Medicine, Healthcare Management

experience:

11 – 15 years

This is an exciting time to join CVS Health, as well Aetna’s Health Care Business, as we collectively accelerate upon our strategy to enhance health care delivery for our members across our suite of clinical program offerings and capabilities. Within the Medicaid Care Management organization, we are supporting continued membership growth and are well positioned within the marketplace with a portfolio of strong products. We are seeking top leadership talent that brings their heart to work every day to join forces and create simplicity for our members.

The VP of Medicaid Care Management will support the organization led by the SVP of Clinical Services. This role is responsible for providing leadership and direction to a large team of clinical and non-clinical colleagues supporting over 2.7 million Medicaid members. Leads day to day operations and manages a large annual operating budget to design, deliver and enhance a suite of holistic clinical engagement programs including Integrated Care Management, LTSS, Foster Care, OH Rise Behavioral Health, field-based care management, population health programs, gaps in care communication and behavioral health programs.

• Development, implementation and oversight of people, processes and technology required to engage with Aetna’s Medicaid members using a population health approach to targeted member engagement. Responsible for clinical program outcomes, interventions, compliance and financial value.

• Responsible for Medicaid Care Management program development and monitoring of quality patient standards, patient and payor satisfaction levels and ensuring that patients are receiving prioritized, clinically appropriate and quality services.

• Scaling, strategic enhancement and day to day operations of the clinical operations including supporting significant growth in operations, clinical platform migration, compliance and operational enhancements to drive year over year cost efficiency improvements across 15+ state plans.

• Monitors care management activities to demonstrate prospective compliance with current federal, state and local contracts, standards, guidelines and regulations.

• Active thought leadership and partnership across the full clinical strategy and model of care for the Medicaid line of business, inclusive of CM and UM program design and driving innovation across the clinical functions to improve performance and member outcomes.

• Leads the integration of CVS assets for the benefit of Medicaid member experience, inclusive of a high degree of interaction with Aetna Behavioral Health, Health Hub, Minute Clinic, and serves as a thought leader in the expansion of our home health engagement in light of expanding enterprise capabilities.

• Collaboration with the Government Lines of Business and Medical Affairs organization, as well as across the growing CVS Health portfolio of assets, to transform the health care experience for CVS customers and Medicaid members.

 
 

REMOTE

10-15% travel expected

Required Qualifications

• 10-15 years leading large matrix clinical organizations

• 10+ years proven strategic relationship building in matrix organizations

• Strong knowledge Medicaid products, including contributing to RFPs.

• Proven success with transformational programs that improve outcomes.

• Experience leveraging Digital technology will be highly valued.

• Proven experience with financial budget planning

• Management Consulting services background will be valued.

COVID Requirements

COVID-19 Vaccination Requirement

CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.

You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.

Preferred Qualifications

• Registered Nurse (RN) or similar clinical background

Education

• Bachelor’s Degree

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. 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://eriebar.org/job/investigative-attorney-medicaid-fraud-control-unit/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

The Office of the New York State Attorney General’s (OAG) Medicaid Fraud Control Unit (MFCU) is seeking an investigative attorney with experience prosecuting or investigating complex financial wrongdoing to serve as a Special Assistant Attorney General in its Buffalo regional office.

Improper and fraudulent use of Medicaid funds can impact access to critical healthcare services for low-income New Yorkers and costs taxpayers millions of dollars annually. MFCU uses the New York State Penal Law, the False Claims Act, Social Services Law §145-b, the Executive Law, and other New York laws to bring civil actions and criminal proceedings to hold accountable individuals and companies who are responsible for these improper or fraudulent Medicaid billing schemes. Many of MFCUs investigations are conducted in coordination with other state, federal or local government and prosecutorial agencies, and have resulted in revenue generation through the large-scale recovery of taxpayer money.

Additionally, MFCU works to safeguard elderly and disabled New Yorkers by investigating reports of abuse and neglect at nursing homes and other residential health care facilities in the state. The importance of this work is highlighted in the OAG’s report detailing allegations of COVID-19-related neglect of nursing home residents across New York State.

The selected attorney will lead collaborative, team-based investigations with MFCU’s forensic accountants/auditors, detectives and analysts to identify and prosecute financial fraud in the healthcare industry and abuse and neglect of residents of healthcare facilities, including presenting evidence to grand juries, and conduct evidentiary hearings and trials in New York State courts. Several recent matters that highlight MFCU’s important work include suing an Orleans County nursing home for years of fraud and neglect; the conviction of an optician for fraudulently billing Medicaid for services for deceased nursing home residents; and securing over $2 million from a western New York doctor to resolve illegal Medicaid billing findings.

Applicants must possess the following minimum qualifications:

• A minimum of four (4) years of practice experience, which should include either a strong foundation in grand jury and criminal trial experience OR substantial complex business litigation practice;
  
• Candidates with a background that includes both prosecutorial and civil litigation experience are strongly preferred;
  
• Prior experience drafting and overseeing the execution of search and eavesdropping warrants is desirable;
  
• Excellent research, analytical, writing and organizational skills;
  
• Sound judgement with the ability to articulate the critical issues in a case accurately and precisely;
  
• Strong interpersonal skills and the ability to work independently and as a member of a team, including
  

fostering productive and collaborative relationships with staff at all levels of the organization; and

• Technology proficiency that preferably includes a knowledge of and comfort using Microsoft Office
  

applications and case management and eDiscovery platforms.

Applicants must reside in (or intend to soon become a resident of) New York State and be admitted to practice law in New York State. In addition, the Public Officers Law requires that OAG attorneys be citizens of the United

States. A two (2) year commitment upon being hired is a condition of employment.

As an employee of the OAG, you will join a team of dedicated individuals who work to serve the people of our State through a wide variety of occupations. To learn more about Assistant Attorney General compensation, please click here. We offer a comprehensive New York State benefits package, including paid leave, health, dental, vision and retirement benefits, and family-friendly policies. Additionally, the OAG offers a robust Workplace Flexibilities Program with multiple options for employees, including telecommuting (up to two days per week) and alternative work schedules.

Per Office of the Attorney General policy, confirmation of vaccination status is a condition of employment for this position. If you are not fully vaccinated, you may be required to provide regular negative COVID-19 PCR test results at a frequency determined by the agency. The agency will consider religious and reasonable accommodations. For more information, please contact recruitment@ag.ny.gov.

HOW TO APPLY

Applications are submitted online. To apply, please click on the following link: MFCU_BUF_SAAG_3548 To ensure consideration, applications must be received by close of business on April 7, 2023.

Applicants must be prepared to submit a complete application consisting of the following:

• Cover Letter

• −  You may address to Legal Recruitment.
  
• −  Indicate why you are interested in a position with the Medicaid Fraud Control Unit and what
  

makes you a strong candidate.

• Resume

• Writing Sample
  
• List of three (3) references
  
• −  Only submit professional references, supervisory references are preferred.
  
• −  Indicate the nature and duration of your relationship to each reference.
  
• −  Include contact information and email addresses for each reference.
  

 
 

• −  Please note, your references will not be contacted until after you interview for the position.
  

  If you have questions regarding a position with the OAG and the application process or need assistance with submitting your application, please contact Legal Recruitment via email at recruitment@ag.ny.gov or phone at 212-416-8080.
  

  For more information about the OAG, please visit our website: ag.ny.gov