Category: MM Curator

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ENROLLMENT- CMS releases latest enrollment figures for Medicare, Medicaid, Children’s Health Insurance Program (CHIP), and ACA Marketplaces

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Your new numbers, ladies and gentlemen.

 
 

Clipped from: https://www.wbiw.com/2023/02/01/cms-releases-latest-enrollment-figures-for-medicare-medicaid-childrens-health-insurance-program-chip-and-aca-marketplaces/

 
 

INDIANA – Tuesday, the Centers for Medicare & Medicaid Services (CMS) released the latest enrollment figures for Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). In addition, last week CMS released the latest number of people that signed up for health care coverage in ACA Marketplaces during the 2022-2023 Open Enrollment Season. These programs serve as key connectors to care for millions of Americans.

Medicare

As of October 2022, 65,236,564 people are enrolled in Medicare. This is an increase of 132,757 since the last report.

35,022,974 are enrolled in Original Medicare.

30,213,590 are enrolled in Medicare Advantage or other health plans. This includes enrollment in Medicare Advantage plans with and without prescription drug coverage.

50,666,744 are enrolled in Medicare Part D. This includes enrollment in stand-alone prescription drug plans and the Medicare Advantage plans that offer prescription drug coverage.

Over 12 million individuals are dually eligible for Medicare and Medicaid, so are counted in the enrollment figures for both programs.

Beginning this month, CMS’ Medicare enrollment data will include low-income subsidy enrollment, including counts of Part D enrollees receiving the full or partial low-income subsidy. Many stakeholders have requested this data and we are pleased to make it available. Detailed enrollment data can be viewed here.

Medicaid and Children’s Health Insurance Program (CHIP)

As of October 2022, 91,342,256 people are enrolled in Medicaid and CHIP. This is an increase of 462,322 since the last report.

84,374,871 are enrolled in Medicaid

6,967,385 are enrolled in CHIP

For more information on Medicaid/CHIP enrollment, including enrollment trends, visit here.

2022-2023 Marketplace Open Enrollment

The Biden-Harris Administration announced that a record-breaking more than 16.3 million people have selected an Affordable Care Act (ACA) Marketplace health plan nationwide during the 2023 Marketplace Open Enrollment Period (OEP) that ran from Nov. 1, 2022-January 15, 2023 for most Marketplaces.  This is an increase of over 1.8 million more people that have signed up for health insurance, or a 13% increase, from this time last year. 

3.6 million plan selections are from people who are new to the Marketplaces, a 21% increase over last year.

12.7 million people who had active 2022 coverage and made a plan selection for 2023 coverage or were automatically re-enrolled.

To view the final Marketplace enrollment snapshot report, click here. 

Every day, CMS ensures that people across the U.S. have coverage that works. See the latest coverage totals across all CMS programs at https://www.cms.gov/pillar/expand-access. This information is updated on a monthly basis. Enrollment data for CMS programs are compiled on different timelines owing to the unique nature of each program.

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MCOS- Centene will pay Indiana $66.5 mln to settle Medicaid overcharge allegations

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: A little over half left in the payout tank.

 
 

Clipped from: https://www.reuters.com/legal/litigation/centene-will-pay-indiana-665-mln-settle-medicaid-overcharge-allegations-2023-02-01/

 
 

  • Managed care giant accused of failing to pass on discounts it received from drugmakers
  • Total settlements with states now top $500 million

Feb 1 (Reuters) – Leading managed care company Centene Corp has agreed to pay Indiana $66.5 million to resolve claims that it overcharged the state’s Medicaid program, for pharmacy benefit management services.

The settlement, announced Tuesday evening by Indiana Attorney General Todd Rokita, is the latest in a string of similar agreements Centene has struck with states over its PBM services, which now total more than $500 million.

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St. Louis-based Centene did not admit wrongdoing under the deal.

“This no-fault agreement reflects the significance we place on addressing [the state’s] concerns and our ongoing commitment to making the delivery of healthcare local, simple and transparent,” the company said in a statement.

Indiana and other states have alleged that Centene, which provides pharmacy benefit management services for state Medicaid programs through its Envolve subsidiary, concealed discounts it received from drugmakers, failing to pass its savings on to Medicaid.

Centene said in its most recent quarterly filing with the U.S. Securities and Exchange Commission that it had settled with 13 states, was in talks with others and had set aside $1.25 billion to resolve related claims.

Previously announced agreements include a $165.6 million settlement with Texas, an $88.3 million settlement with Mississippi and a $33.3 million settlement with Washington.

For Indiana: Chief Deputy Attorney General Lori Torres and W. Lawrence Deas of Liston & Deas

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For Centene: Andrea Kerstein of Locke Lord

Read more:

Centene to pay $33.3 mln to settle Washington Medicaid fraud claims

Centene to pay $144 mln to settle Ohio, Miss. overcharge claims

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PHE- Alaska is scrambling to clear a monthslong food stamp backlog as major Medicaid change looms

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: The HHS agency is hiring 5 security guards to deal with threats from frustrated benefits applicants. I am not making that up.

 
 

Clipped from: https://www.adn.com/alaska-news/2023/01/28/alaska-is-scrambling-to-clear-a-monthslong-food-stamp-backlog-as-major-medicaid-change-looms/

 
 

Lutheran Social Services food pantry in Spenard as photographed on Thursday, Dec. 22, 2022. Food pantries are seeing increased pressure due to a food stamp processing backlog. (Bill Roth / ADN)

A month after a major backlog in Alaska’s food stamp application processing surfaced publicly, state officials are scrambling to hire emergency workers to address delays reaching crisis levels for Alaskans who depend on the federal program to feed their families.

Public frustrations have become so high that the state is hiring security guards to protect existing workers, officials with the state’s Department of Health said.

Meanwhile, another hurdle for the understaffed and overwhelmed Alaska Division of Public Assistance lurks around the corner: recertifying Medicaid applications for the first time since the COVID-19 pandemic began three years ago.

Officials say delays are currently extending to nearly all aid programs administered by the state’s public assistance division. Along with Medicaid and food stamps, those programs also include senior benefits, heating assistance, Temporary Assistance for Needy Families and basic emergency needs assistance for thousands of Alaska families annually.

To address the food stamp backlog and prepare for the Medicaid transition, the state is finalizing an emergency contracting process to hire workers who can sort out applications for benefits, Heidi Hedberg, the state health department’s commissioner-designee, said during a recent presentation to the Senate Health and Social Services Committee. The emergency contract, through the Alaska Department of Law, is expected to condense a two-year training for eligibility workers who process benefits across 18 programs down to two months, with new hires focusing solely on food stamps and Medicaid.

While Division of Public Assistance workers have made some progress working through the delays, Hedberg said, there’s still no firm timeline for clearing the food stamp application backlog.

The division has only finished processing applications through the month of September, she said. Nearly 900 applications for food stamps remain from October, plus an unknown number from November, December and January.

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The public’s frustration with the delays causing some to go hungry is spilling over to the people trying to process their applications.

The department is finalizing a contract to hire security guards for the state’s 11 Division of Public Assistance offices, Hedberg said, later adding she was aware of at least five threats to staff, though there may have been more.

“Alaskans are frustrated they don’t have their benefits,” she said. “When you’re hungry, you get really frustrated and you say things that you may not take action on — but we take everything seriously. We need to make sure that we protect our staff, so that they feel safe in their work environment.”

Short staffing and ‘antiquated’ IT

The extent of the food stamp application processing problem first surfaced in late December when multiple Alaska news outlets, including the Daily News, reported on major delays within the public assistance division, which processes the applications.

Thousands of Alaskans
in many cases had already been waiting months to receive their federally funded food stamp benefits, also referred to as the Supplemental Nutrition Assistance Program, or SNAP. They also reported spending hours on hold with the state’s virtual call center only to be told there was nothing they could do to speed up the process.

Many of the Alaskans calling about food stamps are also experiencing delays for other types of public assistance, including senior benefits, Medicaid and heating assistance, according to the state ombudsman’s office, an independent agency that investigates complaints against the government.

State officials attributed the food stamp application processing delays to a staff shortage, a cyberattack that disrupted online services for months, and an influx of recertification applications in early fall when an emergency pandemic-era program expired in September. The program made it easier for Alaskans to receive maximum benefits without annual recertifications. It ended with the state’s emergency declaration, which wound down in July.

Since December, the director of the Division of Public Assistance has been replaced, and 10 Alaskans have filed a lawsuit alleging that the delays were a violation of federal law.

 
 

Heidi Hedberg, interim commissioner of the Alaska Department of Health, speaks at a news conference on Thursday, Dec. 15, 2022, at the Alaska State Capitol in Juneau. (Photo by James Brooks / Alaska Beacon)

But Hedberg said that at this point, the state doesn’t know just how many food stamp applications still need to be processed: Getting a clear picture of the size of the backlog is complicated by the state’s “antiquated” IT system used to process benefits.

Right now, just one state IT employee, who happens to have experience with an outdated coding language, is able to maintain the food stamp system, she said.

The health department is looking to issue contracts to hire more programmers and eventually start processing benefits with a new IT system, she said.

Staffing recommendation ignored

The public continues to report major problems with the state’s public assistance program.

Kate Burkhart, the Alaska ombudsman, says her office is still receiving between 70 and 100 calls a week about delays with public assistance
—
amounting to
nearly 300 since the beginning of this year, with as many in
the month of January as her office received in all of 2022.

The ombudsman’s office helps connect callers to the Division of Public Assistance if they have waited more than 30 days for assistance, Burkhart said. Staff also have been referring Alaskans to local food banks and pantries while they wait, she said. But not all communities have that resource.

“What we have learned is those programs are extremely packed right now,” Burkhart said. “If you live in a community where there’s no food bank, what do you do?”

[To help fight food insecurity, a community fridge opens in Anchorage’s Mountain View neighborhood]

Burkhart also cited the state agency’s failure to increase staffing — the public assistance program lost 100 positions in 2021 — even after a 2018 investigation by her office that followed very similar complaints about the Division of Public Assistance, including lengthy delays and spotty communication.

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“There’s a reason we recommended adequate staff and maintaining of staffing to address the backlog, and to make sure it didn’t happen again,” she said. “And here we are now.”

A ‘huge’ Medicaid challenge

Once the Department of Health clears the food stamp application backlog, it faces another hurdle: the looming change to Medicaid eligibility, which could soon pose challenges for recipients as well as program operators, Hedberg said. Medicaid, which helps low-income and disabled Americans with health care costs, is operated by states and the federal government.

That issue is expected to come to a head in the coming months.

In exchange for extra federal COVID-19 funding, states agreed in 2020 to keep Medicaid recipients enrolled in the program until the end of the public health emergency. A federal spending bill passed in December ended that moratorium, and normal Medicaid eligibility requirements will resume in April.

Those pandemic-era Medicaid requirements saw a jump in the number of enrollees nationwide. The Kaiser Family Foundation, a nonprofit that studies the health care sector, found that there was a 27.9% increase in enrollments between February 2020 and September 2022.

In Alaska, just over 213,000 people were enrolled in Medicaid as of April 2019. The latest Department of Health data from December showed that over 260,000 Alaskans — or over 35% of the total population — received Medicaid, an increase of 22%.

Starting April 1, the state will need to determine if all of the low-income Alaskans receiving Medicaid are still eligible to receive benefits, a process that will be phased out over a year with monthly reporting requirements as federal Medicaid contributions to the state are also scaled down.

“It’s huge,” said Hedberg.

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[Alaska’s Medicaid backlog violates federal and state law, attorneys say]

Alaskans who lose Medicaid coverage would be eligible to receive benefits through the federal health insurance marketplace, but gaps are possible.

In June 2022, the Department of Health sent a letter to all Medicaid recipients warning them of the upcoming changes. Beneficiaries were told to check that their current mailing address and other contact information was still current, and to check the mail for a letter to re-apply for Medicaid.

Hedberg said the department is looking to contract extra staff to help with the Medicaid recertification process starting in April, but the ongoing food stamps backlog is taking precedence and outreach efforts have been delayed.

As the flood of calls has continued, a virtual call center launched in 2021 has seen its role change as staff became overwhelmed. Previously used by technicians working remotely to process applications from beginning to end, the call center now handles only basic functions, such as callers checking on the status of their applications, Hedberg said.

For now, the plan is for that shift to be only temporary.

Annie Berman reported from Anchorage and Sean Maguire from Juneau.

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FWA- Father, daughter get near identical sentences in Medicaid fraud scheme

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Another personal care services fraud got about $30k from your W2s.

 
 

Clipped from: https://www.wibw.com/2023/01/31/father-daughter-get-near-identical-sentences-medicaid-fraud-scheme/

 
 

FILE(MGN)

WICHITA, Kan. (WIBW) – A father-daughter pair from Wichita have both been sentenced to repay more than $14,000 and $16,000 as well as to serve a year of probation following a Medicaid fraud scheme.

Kansas Attorney General Kris Kobach says that a man from Wichita has been sentenced to repay more than $14,000 to the Kansas Medicaid system following a conviction on two fraud-related charges.

AG Kobach indicated that Johnson Kongvongsay pleaded guilty in December to one felony count of making a false claim, statement or representation to the Medicaid program and one misdemeanor count of unlawful acts concerning computers.

Court records show that Sedgwick Co. District Judge Tylor Roush on Jan. 26 sentenced Kongvongsay to 18 months in jail, however, the jail sentence was suspended and he was ordered to repay the Kansas Medicaid program a total of $14,857.78 and serve a year of supervised probation.

Kobach noted that an investigation found Kongvongsay and his daughter, Kyla, at different points in time had worked as personal care assistants for a relative who was a Medicare beneficiary. Investigators found the pair had submitted false claims and purported to provide personal care services when they were actually working other jobs.

Investigators also found that the pair had committed $30,947.45 worth of fraud.

Kobach indicated that Kyla, 22, also pleaded guilty in December to one felony count of making a false claim, statement or representation to the Medicaid program and one misdemeanor count of unlawful acts concerning computers. She was sentenced to repay $16,089.67 and 12 months of supervised probation.

 
 

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FWA- Eastern District of North Carolina | Illinois Medical Device Manufacturer Agrees to Pay $500,000 to Resolve Allegedly Fraudulent Medicaid Claims

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: A device maker did a backdoor billing / kickback scheme with the help of some local DME providers.

 
 

Clipped from: https://www.justice.gov/usao-ednc/pr/illinois-medical-device-manufacturer-agrees-pay-500000-resolve-allegedly-fraudulent

RALEIGH, N.C. – United States Attorney Michael Easley announced today that Joint Active Systems, Inc. (JAS), a manufacturer of range-of-motion devices located in Effingham, Illinois, has agreed to pay $500,000 to settle civil claims under the Federal and North Carolina False Claims Acts concerning allegations that JAS caused submission of false claims to the North Carolina Medicaid program for certain durable medical equipment.

Specifically, the United States and the State of North Carolina alleged that from January 6, 2012 through January 29, 2021, JAS was unable to directly bill North Carolina Medicaid for its “EZ” range-of-motion devices because JAS did not meet North Carolina Medicaid requirements and/or lacked credentials necessary to do so.  JAS allegedly bypassed those requirements—and its concomitant inability to bill North Carolina Medicaid directly—by entering into arrangements with local North Carolina orthotics and prosthetics providers to bill EZ devices on its behalf.  JAS allegedly directed the local North Carolina orthotics and prosthetics providers to improperly submit claims for JAS EZ devices as orthotics using “L-Codes” under the Healthcare Common Procedure Coding System (“HCPCS”), thereby bypassing the medical necessity reviews and/or authorization processes that may have otherwise taken place.  The Governments alleged that the JAS EZ devices did not qualify for reimbursement as “L-Code” orthotics under North Carolina Medicaid, and that the JAS EZ devices were not listed as reimbursable devices on the North Carolina Medicaid fee schedule.  Indeed, JAS received an official coding verification from the Centers for Medicare and Medicaid Services that designated one of JAS’s EZ devices as an “E-Code” (durable medical equipment) device, not as an “L-Code” (orthotic) device.  The Governments alleged that JAS nevertheless continued to use local North Carolina providers to bill its EZ devices as “L-Code” devices.  In turn, JAS allegedly would pay the local orthotics and prosthetics providers by allowing them to retain a certain amount of the reimbursement.

“The Department of Justice is actively pursuing health care companies and medical device manufacturers who overcharge government healthcare programs,” said United States Attorney Michael Easley.  “We cannot allow companies to bypass rules and regulations to enrich themselves, while depleting taxpayer funds set aside for legitimate patient care.”

“My office’s Medicaid Investigations Division will hold accountable Medical device manufacturers who drain resources from our government healthcare programs, no matter how elaborate and layered the scheme may be,” said North Carolina Attorney General Josh Stein.

The Federal and North Carolina False Claims Acts authorize the Governments to recover triple the money falsely obtained, plus substantial civil penalties for each false claim submitted.  

It should be noted that the civil claims resolved by settlement here are allegations only, that there has been no judicial determination or admission of liability, and that JAS denies the allegations. 

This matter was investigated by the United States Attorney’s Office for the Eastern District of North Carolina and the Medicaid Investigations Division of the North Carolina Attorney General’s Office (“MID”).  Special Deputy Attorney General Matthew R. Petracca, who also serves as a Special Assistant United States Attorney, represented the United States and the State of North Carolina.

The United States Attorney’s Office for the Eastern District of North Carolina, in partnership with law enforcement agencies and state entities, investigates and prosecutes healthcare providers that defraud government programs, including Medicare and Medicaid, and abuse their patients.  The Medicaid Investigations Division investigates and prosecutes healthcare providers that defraud the Medicaid program, patient abuse of Medicaid recipients, patient abuse of any patient in facilities that receive Medicaid funding, and misappropriation of any patients’ private funds in nursing homes that receive Medicaid funding.  To report Medicare fraud or patient abuse in North Carolina, please visit the United States Department of Health and Human Services’ website at https://oig.hhs.gov/fraud/.  To report Medicaid fraud or patient abuse in North Carolina, please call the MID at 919-881-2320.

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FWA- NY Comptroller audit reveals months totaling billions in improper Medicaid payments

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Auditor finds millions in waste, again. State officials say “don’t worry we have it handled,” again.

 
 

Clipped from: https://cbs6albany.com/news/you-paid-for-it/ny-comptroller-audit-reveals-months-totaling-billions-in-improper-medicaid-payments-s-third-party-health-insurance-ny-doh-department-of-health-dinapoli

 
 

 
 

New York State Comptroller Thomas DiNapoli has released an audit of the Department of Health’s Medicaid claims processing program that he says identified more than $22 million in improper Medicaid payments from October of 2021 through March of 2022.

Among the findings from the comptroller, $11.5 million was paid for managed care premiums on behalf of Medicaid recipients who also had concurrent comprehensive third-party health insurance.

MORE: NYS Comptroller: Office of Children and Family Services needs to better-protect children

$8.9 million was paid for clinic, practitioner, inpatient, managed care and laboratory claims that did not comply with Medicaid policies, such as billing in excess of permitted limits.

In response, the Department of Health said the Office of the Medicaid Inspector General continuously performs audits of Medicaid payments, and the DOH says it will continue to work to recover overpayments as appropriate.

MORE: Governor signs bill to restore comptroller’s oversight powers for state contracts

As a result of the audit, about $9.9 million of the improper payments had been recovered by the end of the audit fieldwork.

During the six-month period in question, the DOH processed more than 294 million claims, resulting in payments to providers of nearly $42 billion.

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Expansion (MS)- Every Medicaid expansion bill dies without debate or vote

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: MS lawmakers immune to advocate arguments.

 
 

Clipped from: https://mississippitoday.org/2023/02/01/medicaid-expansion-bills-die/

 
 

Speaker of the House Philip Gunn (AP Photo/Rogelio V. Solis)

More than 15 bills that would have expanded Medicaid to provide health care coverage to primarily the working poor died on Tuesday night without debate or a vote.

No committee chair in either the Senate or House held a hearing on those Medicaid expansion bills. The House Medicaid Committee, where Speaker of the House Philip Gunn assigned all of the his chamber’s expansion bills, did not even meet a single time before the Jan. 31 deadline to consider general bills.

READ MORE: ‘What’s your plan, watch Rome burn?’: Politicians continue to reject solution to growing hospital crisis

Legislative leaders killed the bills as a worsening hospital crisis grips the state and Mississippi continues to be among the unhealthiest states with the highest percentages of uninsured residents.

State Health Officer Dr. Daniel Edney told lawmakers in late 2022 that 38 hospitals across the state are in danger of closing, and all are facing financial hardships. Physicians and hospital leaders have said expanding Medicaid, which would result in more than $1 billion annually in additional federal health care dollars coming to the state, would help hospitals pay their bills. Beyond just helping hospitals, expanding Medicaid would provide health care coverage to many more Mississippians — up to 300,000, according to some studies.

 
 

But many in the Republican leadership of the state, primarily Gunn and Gov. Tate Reeves, have been adamant in their opposition to expanding Medicaid as 39 other states have done, including many led by Republican politicians.

Meanwhile, data shows that support for Medicaid expansion is growing among voters. A Mississippi Today/Siena College poll conducted in early January indicated that the vast majority of the general public, including 70% of Republican voters, favor expansion.

READ MORE: Poll: 80% of Mississippians favor Medicaid expansion

Rep. Robert Johnson, the House Democratic leader from Natchez, said the death of the bills this week was disappointing but not surprising.

Referring to Gov. Reeves’ State of the State speech earlier this week, Johnson pointed out that he spoke of health care alternatives rather than focusing on solutions for hospitals. Those could include stand-alone surgery centers, telemedicine and other alternatives.

“It seems he is talking about providing health care for selected people,” Johnson said, referring to those who would have health care alternatives that often require some type of insurance — either private or public like Medicaid.

While the Medicaid bills died, still alive is a more modest proposal to provide coverage for new mothers on Medicaid for a year instead of the current 60 days. The Senate is expected to pass the bill in the coming days and send it to the House for consideration.

Last year the Senate passed the bill to lengthen postpartum care from 60 days to one year, but it died in the House in large part because of opposition from Gunn and his health care leadership team, Public Health Chair Rep. Sam Mims of McComb and Medicaid Committee Chair Rep. Joey Hood of Ackerman.

While the Medicaid expansion bills all died, Johnson said there might be legislation that is alive where amendments could be offered to expand Medicaid.

“We will be vigilant in looking for every opportunity we can find to offer amendments to expand Medicaid and to provide needed money to hospitals in the short term,” Johnson said. “We have been here a month now and have not addressed that issue.”

READ MORE: Key bills — including Medicaid expansion — to watch in the 2023 Mississippi legislative session

 
 

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Medicaid Certification Consultant – Remote

Clipped from: https://www.indeed.com/viewjob?jk=25c7dde67926c145&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Overview

About Public Consulting Group

Public Consulting Group LLC (PCG) is a leading public sector solutions implementation and operations improvement firm that partners with health, education, technology, and human services agencies to improve lives. Founded in 1986 and headquartered in Boston, Massachusetts, PCG employs approximately 2,000 professionals worldwide—all committed to delivering solutions that change lives for the better. The firm has extensive experience in all 50 states, Canada, and a growing practice in Europe. PCG offers clients a multidisciplinary approach to meet challenges, pursue opportunities, and serve constituents across the public sector. To learn more, visit www.publicconsultinggroup.com.

Responsibilities

The Medicaid marketplace is changing, and PCG is at the forefront. We are looking for an experienced Medicaid Consultant to join our team and help lead our growth efforts. Deep Medicaid experience is critical, as well as experience working with the Centers for Medicare and Medicaid Services (CMS) and the new streamlined modular certification (SMC) and outcomes-based certification (OBC). Our ideal Medicaid Consultant will provide oversight and direction for scope, schedule, , quality, , communications, risk, and , stakeholder management activities, all while adding deep Medicaid and Medicaid Enterprise Systems (MES) experience and thought leadership

Specific Responsibilities:

  • Demonstrated understanding and knowledge of Medicaid, CMS, SMC/OBC, and MES
  • Conduct Medicaid System Assessments
  • Help states plan for and execute SMC/OBC activities
  • Help lead and provide expert level guidance on various projects
  • Ensure planned results are achieved on time
  • Work with clients, vendors, team members to establish and achieve project goals
  • Address problems through risk management and contingency planning
  • Plan, organize, execute, and monitor and control project activities
  • Perform project assessments and report on project progress
  • Facilitate meetings and present project information
  • Identify, document, and/or escalate issues to appropriate levels

Qualifications

Required Skills/Experience:

  • Bachelor’s degree or equivalent university degree
  • 5+ years experience performing project oversight and assessments for a large enterprise grade information technology initiative
  • 4+ years experience performing performance metrics measurements and reporting to management and executive level staff.
  • Demonstrated experience working with SMC/OBC
  • Demonstrated written and verbal communications skills
  • Ability to influence internal and external stakeholders
  • Ability to lead/manage others in a matrixed environment
  • Proficiency in Microsoft applications (Outlook, Word, Excel, PowerPoint, Visio, Project) and project management tools

#LI-AH1

#D-PCG

#LI-remote

Compensation

Compensation for roles at Public Consulting Group varies depending on a wide array of factors including, but not limited to, the specific office location, role, skill set, and level of experience. As required by applicable law, PCG provides the following reasonable range of compensation for this role: $110,000-$140,000

EEO Statement

Public Consulting Group is an Equal Opportunity Employer dedicated to celebrating diversity and intentionally creating a culture of inclusion. We believe that we work best when our employees feel empowered and accepted, and that starts by honoring each of our unique life experiences. At PCG, all aspects of employment regarding recruitment, hiring, training, promotion, compensation, benefits, transfers, layoffs, return from layoff, company-sponsored training, education, and social and recreational programs are based on merit, business needs, job requirements, and individual qualifications. We do not discriminate on the basis of race, color, religion or belief, national, social, or ethnic origin, sex, gender identity and/or expression, age, physical, mental, or sensory disability, sexual orientation, marital, civil union, or domestic partnership status, past or present military service, citizenship status, family medical history or genetic information, family or parental status, or any other status protected under federal, state, or local law. PCG will not tolerate discrimination or harassment based on any of these characteristics. PCG believes in health, equality, and prosperity for everyone so we can succeed in changing the ways the public sector, including health, education, technology and human services industries, work.

Job Type: Full-time

Pay: $110,000.00 – $140,000.00 per year

Work Location: Remote

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Manager, Cost Reporting – Medicaid (Remote)

Clipped from: https://jobs.centene.com/us/en/job/1401919/Manager-Cost-Reporting-Medicaid-Remote?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

You could be the one who changes everything for our 26 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.

Position Purpose:
Responsible for managing and coordinating people and processes involved with filing of cost/expense reports for lines of business across the enterprise. Organizes and directs resources, removes barriers and solves problems in team settings to ensure that the filing process is successful. Cost/expense reports entail categorizing utilization, medical expense, premium, and administrative expenses across types of service, lines of business, and rate cohorts.

An ideal candidate would have …
– Basic knowledge of health care industry and government health plans such as Medicaid etc.
– Basic knowledge of accounting/financial statements and accounting processes etc.
– Basic knowledge of actuarial concepts such as reserving and rate setting etc.
– Basic knowledge of health economics concepts such as MLR, cost and utilization metrics etc.

In this Manager, Cost Reporting role, you will:
•        Manages and coordinates team activities to ensure all regulatory cost reports, supplemental reports, and cost report audits (where applicable) are accurate, in compliance with applicable regulations, have appropriate sign off, and are submitted on time.
•        Collaborates with business leaders across the markets and within finance department (i.e. Accounting, Actuarial, and HealthCare Analytics) to understand and gather the financial data required to produce the required regulatory reports.
•        Utilizes subject matter expertise and provides leadership to interpret evolving cost reporting guidance and to prepare recommendations and solutions to issues in a clear, logical and comprehensive manner. •        Ensures all regulatory cost reports are reconciled to the general ledger, encounter data, and/or audited financial statements.
•        Provides training and coaching to staff on general health care knowledge as well as on specifics of cost/expense reports processes
•        Uses tools to develop processes and implement procedures for gathering, categorizing, and allocating claim and financial data.  Tools include data warehouse tables, EDW data, actuarial data, access databases, and Excel spreadsheets.
•        Manages the implementation of new programs, strategies, and process improvements.
•        Performs ad-hoc reconciliations and work on special projects, as required.

Important Note: 
This position is fully remote.  However, due to the needs of the business, candidate must be available to work a Eastern Standard Time (EST) schedule.

Education/Experience:
– Bachelor’s degree in Finance, Accounting, Economics, Actuarial Science, Mathematics, Statistics, or related field. Master’s degree preferred.

– 5+ years of financial/cost reporting or related experience. Knowledge of generally accepted accounting principles, GASB and FASB statements and standards.

Preferred Experience/Knowledge:

– Basic knowledge of health care industry and government health plans such as Medicaid etc.

– Basic knowledge of accounting/financial statements and accounting processes etc.

– Basic knowledge of actuarial concepts such as reserving and rate setting etc.

– Basic knowledge of health economics concepts such as MLR, cost and utilization metrics etc.

License/Certification:
– CPA/ASA preferred

Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

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DIRECTOR, Encounters (MEDICAID) – REMOTE

Clipped from: https://jobs.wjtv.com/jobs/director-encounters-medicaid-remote-new-york/898990519-2/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Under the general direction the SVP, Integration & Innovations is responsible for the strategy, design, and management of the team that will implement companywide initiatives impacting:
Encounters Accuracy & Completeness (ie Encounter Production, Audit, Production Vendor Oversight) for all lines of business.
Responsible for centralizing all corec encounter submission processes including identification of any vendor or system support requirement for most effective and accurate processing. Assessment of resources across the organization for purposes of centralization and establishing an Encounters Center of Excellence
Assume all (Encounter) submissions currently sitting in Risk Adjustment to ensure standardization, completeness and accuracy of submissions
Develop and implement all montoring reporting needed for optimized outcomes and reduce/eliminate financial penalties.
Responsible for increasing volume of encounters received from providers, improve completeness of encounter data with states, CMS, HHS to reconcile data.
Implemented processes to monitor rejected encounters to correct and resubmit where applicable
Improve submission accuracy for frequent occurring error codes and create systemic imporvements
Standardize State/LOB reporting increasing visibility into accuracy & completeness
Centralize and automate standardized resources, requirements and encounter tranformation
Encounter submissions, rejection management & resolution for all lines of business including internal strategic partnerships supporting the production of encounters including but not limited to the Corporate Recovery Team, Corporate Claims Compliance Team, Support Services, Enrollment and Billing, Encounters Team as well as providing overall organizational leadership aimed at managing overall healthcare costs.
Hires, coordinates training and manages staff involved in creating controls, documents and tools within the Encounter process in order to manage work in any of the assigned resources.
Identifies, develops and trains appropriate staff and implements processes to standardize the overall ends-to-end processing, management and accuracy of encounters, as well as working with partner departments to implement process improvements impacting quality and timeliness of encounters processing and accuracy.
Ongoing monitoring and management rhgouth resolution any potential penalities related to accuracy and timliness of encounters submissions.
Initiates staff and coordinates needed projects around various systems enhancements, conversions and upgrades. These projects improve QNXT Claims MASS Adjudication results, enhances the Corporate Operations claims quality and reduces unit claims costs by reducing rework (both underpayments and overpayments) for all lines of business.
Identifies projects/initiatives that reduce administrative costs for Molina and/or providers as well as identifies opportunities to ensure accurate encounters are occurring to assist in the management of the organizational health care costs for all lines of business and directly impacting Risk Revenue and Quality Compliance. Convenes work groups, develops implementation plans with identified tasks, timelines and assigned parties. Executes and measures success.
Participates with others in the Corporate Operational Leadership Team along with IT to analyze the root cause of information of variations to the encounters, to find/propose ways to improve
upon performance results, to identify potential risks to the organization and to lead the needed changes within the encounters process to support the organizational needs in all lines of business.
Collaborate with leadership, peers, and business partners to establish encounters improvement objectives and execute business priorities based on strategic goals in the operational plan.
Works with the Training Team in preparing needed documentation around training of new/existing staff while also assisting in preparing needed Guidelines to assist in the timely and accurate processing of encounters for all lines of business.
Manages direct Molina staff as well as oversees vendors involved in any of the areas reporting to the VP, Core Operations – Encounters to enable the organization to produce operational results at the lowest possible cost, the most consistent and compliant service levels and the highest level of quality for all lines of business.
Ensures all state, federal and Molina regulations, Policies/Procedures and SOPs are implemented and followed on a consistent basis to ensure the highest compliance possible within the Corporate Operations areas.
Sets and manages overall costs to meet/exceed annual budgets and finds ways to improve productivity and automation wherever possible to reduce unit costs and overall G&A for the organization.
Design and implement systematic approach to improve member and provider experiences through increased operational efficiency and effectiveness.
Responsible for reporting potential liabilities for financial tracking and accruals to senior leadership.
Excellent verbal and written communication skills.
Ability to influence and drive change among peers and others within the Molina organization.
Skill to envision, craft proposals, obtain consensus around approving and implementing future state processes and systems needed to support strategic direction set by organization.
Ability to abide by Molinas policies.
Ability to maintain attendance to support required quality and quantity of work.
Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.
Other duties as assigned.