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Medicaid Eligibility Specialist, FT, Mon – Broward Health Corporate | Fort Lauderdale, FL

Clipped from: https://www.simplyhired.com/job/IbwqotG_Klt34Nu29qCapLTWqk9foX1CsEp59ePjJ6RzWIVoZxLGSQ?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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Medicaid Program Monitor Job Opening in Baton Rouge, LA at State of Louisiana

Clipped from: https://www.salary.com/job/state-of-louisiana/medicaid-program-monitor/9a7c37f2-49c5-4d2e-aef4-dcb5ee2c004e?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

State of Louisiana

 
 

 Baton Rouge, LA Other

Job Posting for Medicaid Program Monitor at State of Louisiana

This position is located within the Louisiana Department of Health / Medical Vendor Administration / Eligibility Field Operations / East Baton Rouge Parish
 
 Announcement Number: MVA/CSH/169914
 Cost Center: 3052050400
 Position Number(s): 50656481, 50656480, 50656482
 
This is a promotional opportunity open only to classified employees with permeant status with Louisiana Department of Health.

These positions will be filled as:

Medicaid Program Monitor (Quality Assurance Specialist)
Medicaid Program Monitor (Trainer)

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

 
To apply for this vacancy, click on the “Apply” link above and complete an electronic application, which can be used for this vacancy as well as future job opportunities. Applicants are responsible for checking the status of their application to determine where they are in the recruitment process. Further status message information is located under the Information section of the Current Job Opportunities page.
 
*Resumes WILL NOT be accepted in lieu of completed education and experience sections on your application. Applications may be rejected if incomplete.*
 
A resume upload will NOT populate your information into your application. Work experience left off your electronic application or only included in an attached resume is not eligible to receive credit
 
For further information about this vacancy contact:
 Casey Hickman
 Casey.Hickman@la.gov
 LDH/HUMAN RESOURCES

 BATON ROUGE, LA 70821
 225 342-6477
 
 This organization participates in E-verify, and for more information on E-verify, please contact DHS at 1-888-464-4218.      

MINIMUM QUALIFICATIONS:

A baccalaureate degree plus three years of professional level experience in administrative services, economics, public health, public relations, statistical analysis, social services, or health services.

 
 

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

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


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


30 to 59 semester hours credit will substitute for one year of experience towards the baccalaureate degree.

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

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

 
 

Graduate training with eighteen semester hours in one or any combination of the following fields will substitute for a maximum of one year of the required experience on the basis of thirty semester hours for one year of experience: public health; counseling; social work; psychology; rehabilitation services; economics; statistics; experimental/applied statistics; business, public, or health administration.

 
 

A master’s degree in the above fields will substitute for one year of the required experience.

 
 

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

 
 

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

 
 

A Ph.D. in the above fields will substitute for two years of the required experience.

 
 

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

 
 

NOTE:

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

Function of Work:
To perform advanced research, analyses, and/or policy management activities for Medicaid programs.

Level of Work:

Advanced.

Supervision Received:

Broad from a Medicaid Program Supervisor or above.

Supervision Exercised:

None.

Location of Work:

Department of Health and Hospitals, Medical Vendor Administration.

Job Distinctions:

Differs from Medicaid Program Specialist 2 by the presence of advanced research, analysis and policy management responsibility.

Differs from Medicaid Program Supervisor by the absence of supervisory responsibility.Conducts audits of eligibility enrollment applications; prepares reports on results of each audit.


Prepares, interprets and clarifies eligibility policies and procedures.


Revises rules, regulations, and procedures to meet changes in law or policy.


Compiles data and proposes budgets for subprogram studies and proposed legislation; determines programmatic impact and composes response for

fiscal statements and fiscal notes.

Reviews current and proposed state and federal regulations and/or revisions to those regulations for hospitals and home health providers.


Evaluates new and/or revised regulations to determine the impact to the state Medicaid program.


Reviews audits performed by the contracted auditor to determine compliance with federal and/or state policies and regulations, which affect allowable costs.


Coordinates compliance monitoring of Medicaid Application Centers statewide.


Receives, approves and schedules all requests for Application Center Representative training.


Advises and assists field staff in performing on-site monitoring reviews to ensure that the Application Centers adhere to federal, state and agency

rules and regulations.

Assist in negotiating contractual agreements between the Department of Health and Hospitals and the Application Centers.


Provides functional supervision over contract staff.


Monitors and evaluates training provided by contract staff.


Prepares the annual budget request utilizing the prescribed format and addendums issued by the Office of Planning and Budget. Prepares detailed analyses

and narratives supporting and/or justifying the request as submitted. Responds to requests for additional information and modifications to the budget during
the legislative approval process.

Trains staff of all Medical Vendor Administration sections in fiscal management, budget development and variance reporting.


Develops training module and provides essential guidance to managers regarding preparing accurate, pertinent and substantiated data.

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Director,Technology: Health Plan CIO Medicaid Job Missouri

Clipped from: https://www.learn4good.com/jobs/online_remote/info_technology/2035910765/e/

Position:  Director, Technology: Health Plan CIO – Missouri Medicaid
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Come make an impact on the communities we serve as we help advance health equity on a global scale.

Here, you will find talented peers, comprehensive benefits, a culture guided by diversity and inclusion, career growth opportunities and  

** your life’s best work. (sm)
** As an individual contributor you will be part of the local leadership team working with internal and external partners to support the successful delivery and maintenance of Information Systems that support the United Healthcare Missouri Medicaid business.  

You will also be part of a broader team of individual contributors who provide thought leadership and strategic alignment across the Medicaid technology organization.  The successful candidate with have demonstrated experience in leading matrixed teams, proven skills driving implementation of programs and initiatives, experience in working with senior leadership and strategic planning in the healthcare industry.


This role requires excellent communication, problem solving skills, curiosity and the ability to be both a doer and a leader.  The quality candidate can leverage their business knowledge in the healthcare industry to support daily efforts, innovative IT efforts, and must excel in high impact and escalated crisis situations.  This position will be a key contact for IT efforts and will work with the appropriate delivery areas for Community & States IT projects for our Missouri business.


The overall goal of this position is to provide executive oversight and leadership in United’s strong matrix environment, so the IT needs of the business and state partners are met, and contractual compliance are achieved.


If you are located in the St. Louise area, you will have the flexibility to work remotely 1-2 days a week*, as well as work in the office as you take on some tough challenges.

*
* Primary Responsibilities:

**+ Relationship Building:+ Build and improve state, Health plan, IT and service unit partnerships to build long-lasting transparent and trusting relationships+ Represents United Healthcare at State meetings; interacts with Community & State senior health plan and shared services leaders+ Leadership:+ Influence, negotiate effectively, and provide recommendations to arrive at win-win solutions with our state partner, Health plan, IT and business service partners related to IT initiatives+ Lead change and innovation by demonstrating emotional resilience, managing change by proactively communicating the case for change and promoting a culture that thrives on change+ Influence Health Plan, Business Service units, State partners, IT teams employees by fostering teamwork and collaboration, driving employee engagement and leveraging diversity and inclusion+ Provide leader oversight and direction to ensure that the IT applications and operations are working effectively, through high levels of engagement with Health Plan leaders and service units+ Develop and mentor others while also building awareness to your own strengths and development needs+ Active participant in local/regional health plan leadership, operational leadership group, business goals and strategic initiatives+ Be a strategic leader contributing to the growth agenda+ Regulatory and Growth Effectiveness:+


Provides SME (Subject Matter Experience) on business capabilities, such as claims, member, clinical, provider, X.12 transactions, etc to provide a translation of business need into technical requirements for both Growth and regulatory IT initiatives+ Strategize and review with business leaders to identify and frame their IT needs, mapping them to strategic plans and prioritizing them+ Drive high-quality execution and operational excellence by communicating clear directions and expectations+ Play an active role in implementing innovation solutions by challenging the status quo and encouraging others to improve overall effectiveness+ Support Program and Project Managers to ensure that programs / projects are delivered on-time, on-budget, on benefit and on-quality and intervene to resolve issues as required+ Represent United at mandatory state meetings and influence the design and timeline of state requirements through written recommendations, questions and clarifications, and open feedback forums+ Collaborate with other MCOs (Managed Care Organizations) to drive common processes and timelines for state deliverables+ Performance & Satisfaction:+


Accountable for compliance with state requirements for transaction loading (834, 837, 820, provider files, etc) and compliance on our technology platforms with state needs+ Drive sound and disciplined decisions that drive action while effectively using IT and Healthcare business knowledge+ Provides…

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Senior Business Analyst Medicaid ACO – Steward Health Care System

Clipped from: https://pm.healthcaresource.com/cs/steward/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic#/job/106342

Position Purpose: Reporting to the Senior Manager of Analytics and in support of the Director of Medicaid ACO, the Senior Clinical Healthcare Analyst will demonstrate strong knowledge of performance indicators and deliver actionable data and key business insights to the Steward Health Care Network (SHCN)’s Medicaid Accountable Care Organization.

  • Conducts sophisticated business analyses to support Medicaid ACO program development and ongoing operations, grounded in deep expertise and functionality with both SHCN Enterprise data warehouse and publicly available Medicaid-related health care data sources
  • Analyze and recommend opportunities and financial impacts of strategic partnerships, new Medicaid programs, and key Medicaid ACO related initiatives
  • Build predictive models that provide Operations and Clinical Care Management Teams with targeted member outreach and engagement activities for improved health outcomes
  • Respond to government requests for data that demonstrate statistically significant health outcomes towards program improvement goals in the areas of cost effectiveness and quality
  • Collaborate with Steward’s Analytics, and Informatics teams to maintain proper data governance oversight and data integrity management of the MassHealth data
  • Other duties as assigned based on business needs

 
 

Education / Experience / Other Requirements

Education:   

  • Bachelor’s degree required; Master’s preferred

Years of Experience:  

  • 3-5 years of relevant experience in healthcare, analytics, or informatics

Specialized Knowledge:  

  • Demonstrated knowledge of health plan claims data and familiarity with Medicaid and other public programs 
  • Possess strong skills in SQL, Excel, Access, PowerPoint, and BI visualization tools, preferably tableau
  • Data science applications (e.g., R, Python, etc.) to build predictive models
  • Strong understanding of statistical concepts (Probability Distribution, Dimension Reduction, Bayesian Statistics)
  • Organizational and project management skills to manage projects effectively
  • Excellent verbal and written communication skills, including data visualization to present complex data analysis, outstanding interpersonal skills
  • Commitment to service excellence; Ability to deliver timely and accurate work product to a broad customer base. 

  

Physical and Mental Demands

These physical and mental demands are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 
 

☒    Talking

☒    Hearing

☐    Standing

☐    Repetitive Motion

☒    Visual Acuity

☐    Walking

☐    Lifting <20 lbs

☐    Lifting >20 lbs

☐    Reaching

☐    Climbing

☐    Pushing / Pulling

☐    Stooping / Crouching

☐    Sedentary Work

☐    Light Work

☐    Medium Work

☒    Critical Thinking

☒    Mental concentration

☐    Driving

 

Posted on

Medical Director- Utilization Review Management Medicaid Job North Carolina

Clipped from: https://www.learn4good.com/jobs/online_remote/healthcare/2035811060/e/

Position:  Medical Director- Utilization Review Management for Medicaid
 

Position

Title:


 

Medical Director
– Utilization Review Management for Medicaid

Job Description:

 

Medical Director

Location:

Remote/Work from Home position. Strongly prefer candidates to live in North Carolina.


Must be
able to work eastern time zone hours.

Build the Possibilities. Make an extraordinary impact.

Responsible for the administration of physical and/or behavioral health medical services, to ensure the appropriate and most cost-effective medical care is received. May be responsible for developing and implementing programs to improve quality, cost, and outcomes. May provide clinical consultation and serve as clinical/strategic advisor to enhance clinical operations. May identify cost of care opportunities. May serve as a resource to staff including Medical Director Associates.

May be responsible for an entire clinical program.

How you will make an impact:

  • Supports clinicians to ensure timely and consistent responses to members and providers.
  • Provides guidance for clinical operational aspects of a program.
  • Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations, and patients’ office visits with providers and external physicians.
  • May conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations.
  • Serves as a resource and consultant to other areas of the company.
  • May be required to represent the company to external entities and/or serve on internal and/or external committees.
  • May chair company committees.
  • Interprets medical policies and clinical guidelines.
  • May develop and propose new medical policies based on changes in healthcare.
  • Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes.
  • Identifies and develops opportunities for innovation to increase effectiveness and quality.

Minimum Requirements:

 

  • Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS), American Osteopathic Association (AOA) or National Board of Physicians and Surgeons (NBPAS).
  • Must possess an active unrestricted medical license to practice medicine or a health profession.
  • Must possess or have the ability to obtain a North Carlina medical license.
  • Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US.
  • Minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
  • Additional experience may be required by State contracts or regulations if the Medical Director is filing a role required by a State agency.
  • If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a sensitive position’ work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions.
  • Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties, principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions.

Preferred

Qualifications:


 

  • Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed.
  • Internal Medicine, Family Medicine, or OB/GYN specialties preferred. Other specialties will be considered.

Job Level:

Director Equivalent

Workshift:

Job Family:

MED &gt;
Licensed Physician/Doctor/Dentist

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

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

Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at …

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Medicaid Specialist – Sentara Health

Clipped from: https://www.sentaracareers.com/job/17691142/medicaid-specialist-norfolk-va/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

At Sentara Healthcare, one of our values is to keep you safe.
Sentara Healthcare and many other companies across the US are being targeted by cyber criminals who are impersonating representatives of the company, claiming to have job offers. Sentara will never ask you for banking or personal identification information via email or text. We will never ask an applicant to pay money for training, supplies, or other so-called expenses. If you suspect you have received a fraudulent job offer, e-mail taadmin@sentara.com.

Award-winning: Sentara Healthcare is a Virginia and Northeastern North Carolina based not-for-profit integrated healthcare provider that has been in business for over 131 years. Offering more than 500 sites of care including 12 hospitals, PACE (Elder Care), home health, hospice, medical groups, imaging services, therapy, outpatient surgery centers, and an 858,000 member health plan.  The people of the communities that we serve have nominated Sentara “Employer of Choice” for over ten years.  U.S. News and World Report has recognized Sentara as having the Best Hospitals for 15+ years.  Sentara offers professional development and a continued employment philosophy!

When you join Sentara in a professional or management role, you become part of a progressive team of business leaders and operational experts. Our organization and our people are highly respected for the knowledge and innovation that we demonstrate each day. Working with us is an opportunity to have a positive influence on our growth and the communities we serve.

Overview

Responsibilities

Qualifications

Overview

Responsibilities

Assists in gathering and processing intake and enrollment paperwork. Submits and completes follow-up of pre/post enrollment paperwork with state and federal agencies. Completes verification of Medicare and Medicaid coverages and coordination of annual Medicaid renewals. Works in collaborations with Account Executive, Enrollment Coordinator, potential participant, caregiver, and others to identify a potential enrollee’s current financial status through review of income sources, current insurance policies, bank accounts, and other areas. Assists the Account Executive and Enrollment Coordinator in explaining financial issues to potential enrollees and/or their caregivers related to enrollment in the SE PACE program. Assists with quarterly mailings to referral sources as assigned. Other projects and duties as assigned. Associates Degree, preferred and 1-2 two years of extensive knowledge of Virginia Medicaid

Qualifications

License/Certification

  • Basic Life Support (BLS) – Other/National

Education

  • Associate’s Level Degree
  • High School Grad or Equivalent

Experience

  • Medicaid 1 year
  • Frail and Elderly Population Previous Experience
  • Customer Service 3 years

Skills

  • Microsoft Office

 
 

Sentara Healthcare prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

Posted on

Director, Medicaid Solutions | Centene Corporation

Clipped from: https://www.linkedin.com/jobs/view/director-medicaid-solutions-at-centene-corporation-3451137055/?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 Build the company’s market position and increase revenue by directing and performing activities to locate and develop new business opportunities.


Propose potential business opportunities by contacting potential stakeholders and partners, discovering and exploring opportunities


Screen potential business opportunities by analyzing market strategies, deal requirements, potential and financials, evaluating options, and resolving internal priorities


Develop business development strategies and positions by studying integration of new opportunities with company strategies and operations, examining risks and potentials, and estimating stakeholders’ needs


Formulate and communicate to stakeholders, including regulators or other government officials and providers, provide leadership and direction to functional leadership involved with stakeholders to ensure objectives are met


Coordinate requirements, develop and negotiate contracts, and integrate contract requirements with operations


Participate in developing business and operational delivery models


Ensure compliance with applicable laws, Medicare and/or Medicaid regulations


Serve as a contact for functional groups, various departments and external customers in the coordination of implementation for multiple projects


Travel 30% – 50%


Education/Experience Bachelor’s degree in Business Administration, Economics, Political Science or related field. Master’s degree preferred. 7+ years of business development, sales, government relations or legal affairs, mergers and acquisitions, or investment analysis experience. Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff. Experience with healthcare, managed care, Medicaid or Medicare 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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Provider Compliance Investigator – REMOTE OPTIONS

Clipped from: https://www.azstatejobs.gov/jobs/provider-compliance-investigator-remote-options-arizona-united-states-phoenix?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Arizona Health Care Cost Containment System
Accountability, Community, Innovation, Leadership, Passion, Quality, Respect, Courage, Teamwork

The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, is driven by its mission to deliver comprehensive, cost-effective health care to Arizonans in need. AHCCCS is a nationally acclaimed model among Medicaid programs and a recipient of multiple awards for excellence in workplace effectiveness and flexibility.


AHCCCS employees are passionate about their work, committed to high performance, and dedicated to serving the citizens of Arizona. Among government agencies, AHCCCS is recognized for high employee engagement and satisfaction, supportive leadership, and flexible work environments, including remote work opportunities. With career paths for seasoned professionals in a variety of fields, entry-level positions, and internship opportunities, AHCCCS offers meaningful career opportunities in a competitive industry.


Come join our dynamic and dedicated team.

Provider Compliance Investigator

Office of Inspector General
 

Job Location:

Address:  801 E. Jefferson Street, Phoenix, AZ 85040

Posting Details:

Open until filled

Salary: 47,300 – 57,200 

Grade: 21

This position may offer the ability to work remotely within Arizona based upon the department’s needs and continual meeting of expected performance measures.   

Job Summary:

The Division of Inspector General is looking for a highly motivated individual to join our team as a Provider Compliance Investigator. This position is directly involved in negotiating the final determination of financial over-payments and recommending civil monetary penalties levied against providers participating in fraudulent billing practices. The information obtained by this position is used for a variety of activities such as: determination of fines, restitution and cost avoidance; internal deliberation’s regarding settlement amounts for fines and restitution, participate in the decisions regarding opening and closing of criminal and civil investigations.

Major duties and responsibilities include but are not limited to: 

  • Complete required health care fraud audits to establish if program violations have occurred through billing, health care records, financial documentation, access to mainframe computer systems at AHCCCS, DES, MVD and DPS.
  • Develop and prepare complex spreadsheets and flow-charts indicating under payments, misuse of funding and billings obtained through the audit process. 
  • Develop overpayments: losses to the Medicaid Program through diligent research and review to present the evidence to the legal authorities for prosecution. 
  • Communicate effectively with the providers and contractors occasionally under adverse arid threatening circumstances. Authority to draft and serve subpoenas and take sworn statements. 
  • Conduct interviews and obtain written statements from providers and clients to determine if fraudulent activities have occurred. Prepare written reports for use in administrative or legal proceedings.

Knowledge, Skills & Abilities (KSAs):

Knowledge: 

  • Law Enforcement processes and protocols, Basic investigative techniques. 
  • Interviewing suspects, witnesses, and victims, and of the rules regarding the admissibility of statements, admissions, and confessions. 
  • Thorough knowledge of HIPAA and the rules pertaining to the sharing of investigative information, Relevant statutes and laws pertaining to the investigation of Medicaid fraud, waste, and abuse. 
  • Claims processing, procedures, financing and operations for Fee For Service and Medical Compliance Officers, preparation of computerized spreadsheets which support audit findings.

Skills:

  • Legal decisions as they relate to the admissibility of evidence, confessions, admissions, and statements. 
  • Proper methods of interviewing suspects, witnesses, and victims, and of the rules regarding the admissibility of statements, admissions and confessions. 
  • Effective methods to conduct a covert operation to identify fraudulent activity, Investigative methods, techniques, and approaches, necessary to plan and conduct criminal, civil and administrative investigations relating to the operations and activities of AHCCCS, conflict resolution. 

Abilities:

  • Interpreting and applying Federal and State Statutes and Agency policies. 
  • Conduct investigations, Manage time effectively, deal with difficult situations in a calm manor. 
  • Effectively handle hostile situations. 
  • Function in a virtual office environment.

Qualifications:

Minimum: 

  • Bachelor’s Degree in accounting or closely related field or at least two years’ experience as an Auditor or equivalent.

Preferred: 

  • Certified Professional Coder (CPC), Certified Fraud Examiner Certification (CFE), and/or eligibility experience. Knowledge of Title 19, ASRS 13 and 36 (is preferred but not required)

Pre-Employment Requirements:

• Successfully complete the Electronic Employment Eligibility Verification Program (E-Verify), applicable to all newly hired State employees.
• Successfully pass fingerprint background check, prior employment verifications and reference checks; employment is contingent upon completion of the above-mentioned process and the agency’s ability to reasonably accommodate any restrictions.
• Travel may be required for State business. Employees who drive on state business must complete any required driver training (see Arizona Administrative Code R2-10-207.12.) AND have an acceptable driving record for the last 39 months including no DUI, suspension or revocations and less than 8 points on your license. If an Out of State Driver License was held within the last 39 months, a copy of your MVR (Motor Vehicle Record) is required prior to driving for State Business. Employees may be required to use their own transportation as well as maintaining valid motor vehicle insurance and current Arizona vehicle registration; however, mileage will be reimbursed.

Benefits:

Among the many benefits of a career with the State of Arizona, there are:
• 10 paid holidays per year
• Paid Vacation and Sick time off (13 and 12 days per year respectively) – start earning it your 1st day (prorated for part-time employees)
• A top-ranked retirement program with lifetime pension benefits
• A robust and affordable insurance plan, including medical, dental, life, and disability insurance
• Participation eligibility in the Public Service Loan Forgiveness Program (must meet qualifications)
• RideShare and Public Transit Subsidy
• A variety of learning and career development opportunities
• Opportunity to work 100% virtually or remotely on an ad-hoc basis (home office)

By providing the option of a full-time or part-time virtual/remote work schedule, employees enjoy improved work/life balance, report higher job satisfaction, and are more productive. Remote work is a management option and not an employee entitlement or right. An agency may terminate a remote work agreement at its discretion.

For a complete list of benefits provided by The State of Arizona, please visit our benefits page

Retirement:

Lifetime Pension Benefit Program
• Administered through the Arizona State Retirement System (ASRS)
• Defined benefit plan that provides for life-long income upon retirement.
• Required participation for Long-Term Disability (LTD) and ASRS Retirement plan.
• Pre-taxed payroll contributions begin after a 27-week waiting period (prior contributions may waive the waiting period).

Deferred Retirement Compensation Program

• Voluntary participation.
• Program administered through Nationwide.
• Tax-deferred retirement investments through payroll deductions.

Contact Us:

Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by emailing careers@azahcccs.gov.
Requests should be made as early as possible to allow time to arrange the accommodation. Arizona State Government is an AA/EOE/ADA Reasonable Accommodation Employer.

Posted on

Social Worker Care Manager – Medicaid Job Orange California

Job Description

The goal of the Care Manager, Social Worker is to advocate for and assist the patient in the achievement of optimal health, access to care, and appropriately utilizing resources. The Care Manager Social Worker utilizes the following processes to meet the patient’s individual healthcare needs: assessment, planning, implementation, coordination, monitoring and evaluation of the plan of care. The management of resources and the coordination of the continuum of care will be performed in a manner consistent with the mission vision and core values of St.


Joseph Health. Required qualifications:

Master’s Degree in Social Work, Psychology, Counseling, Or Master’s Degree with five (5) years relevant social work experience. Driving may be necessary as part of this role. Caregivers are required to comply with all state laws and requirements for driving. Caregivers will be expected to provide proof of driver license and auto insurance upon request. See policy for additional information. 6 months Clinical experience in an HMO, medical group, affiliated model, hospital or medical office/clinic setting.

3 years Utilization management and/or case management highly desirable   Preferred qualifications:

Certification in Case Management (CCM, ACM) Psychiatric chemical dependency treatment. Managed care experience.  Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally, and achieving financial security. We take care of you, so you can focus on delivering our Mission of caring for everyone, especially the most vulnerable in our communities.

About UsAt Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected.


Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.  


The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities. Check out our benefits page for more information about our Benefits and Rewards.


About the Team Providence Physician Enterprise (PE) is a service line within Providence serving patients across seven states with quality, compassionate, coordinated care. Collectively, our medical groups and affiliate practices are the third largest group in the country with over 11,000 providers, 900 clinics and 30,000 caregivers. PE is comprised of Providence Medical Group in Alaska, Washington, Montana and Oregon;

Swedish Medical Group in Washington’s greater Puget Sound area, Pacific Medical Centers in western Washington;
Kadlec in southeast Washington;
Providence’s St. John’s Medical Foundation in Southern California;
Providence Medical Institute in Southern California;
Providence Facey Medical Foundation in Southern California;
Providence Medical Foundation in Northern and Southern California; and Covenant Medical Group and Covenant Health Partners in west Texas and eastern New Mexico.

We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment.


We are committed to cultural diversity and equal employment for all individuals. It is our policy to recruit, hire, promote, compensate, transfer, train, retain, terminate, and make all other employment-related decisions without regard to race, color, religious creed (including religious dress and grooming practices), national origin (including certain language use restrictions), ancestry, disability (mental and physical including HIV and AIDS), medical condition (including cancer and genetic characteristics), genetic information, marital status, age, sex (which includes pregnancy, childbirth, breastfeeding and related medical conditions), gender, gender identity, gender expression, sexual orientation, genetic information, and military and veteran status or any other applicable legally protected status.


We will also provide reasonable accommodation to known physical or mental limitations of an otherwise qualified caregiver or applicant for employment, unless the accommodation would impose undue hardship on the operation of our business.


We are a community where all people, regardless of differences, are welcome, secure, and valued. We value respect, appreciation, collaboration,…

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Provider Network Account Executive II [Medicaid Expert] | AmeriHealth Caritas

Clipped from: https://www.linkedin.com/jobs/view/provider-network-account-executive-ii-medicaid-expert-at-amerihealth-caritas-3447529976/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

Your career starts now. We’re looking for the next generation of health care leaders.

 
 

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation’s leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

 
 

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at

 
 

The Provider Services AE II is responsible for building, nurturing and maintaining positive working relationships between Plan and its key contracted providers. Assigned provider accounts may include single or multiple practices in single or multiple locations, health systems, integrated delivery systems or other provider organizations. Provider Services AE II maintains in depth understanding of Plan’s contracts and provider performance and needs, identifying, developing and conducting relevant and tailored provider orientation sessions, making educational visits and working to resolve provider issues. Ensure that network provider perspectives and feedback are included in evaluations of improvement initiative successes; Collaborate with other ODM-contracted managed care entities to simplify provider requirements and remove administrative barriers; and Develop and implement the MCO’s provider claim dispute resolution process Collaborates with Provider Network Operations to resolve Provider concerns timely. Maintains complete understanding of Plan reports and metrics and uses them to evaluate the performance of assigned providers/practices/facilities, determining, communicating and implementing plans for providers to improve performance and measuring ongoing performance. Uses data to develop and implement methods to improve relationship. Assists in corrective actions required up to and including termination, following Plan policies and procedures. Supports the Quality Management department with the credentialing and re-credentialing processes, investigation of member complains and any potential quality issues. Maintains a functional working knowledge of Facets, including the provider database and routinely relays information about additions, deletions or corrections to the Provider Maintenance Department. Maintains and delivers accurate, timely activity and metric reports as required. Identifies and maintains strong partnerships with appropriate internal resources and stakeholders.

 
 

An AE II’s Accounts/assignments Include

 
 

  • Those that are most complex, a higher number of multiple practice locations and multi-specialty practices and multiple providers and/or a large health system.
  • Those that impact a total member population of a minimum of 5,000 or more. The appropriate minimum number of member population impact for the Provider Services AE II level is determined by each Plan according to their business environments.

 
 

Will develop/implement/manage programs and projects that support/impact high dollar and high member provider groups.

 
 

The Provider Services AE II is responsible for participating or independently developing and implementing Provider Network education programs and materials (both internal and provider targeted) and is assigned to train, mentor and support new AE’s. The AE II will assist AE I’s in resolving/managing issues with Providers.

 
 

Education/ Experience

 
 

  • Bachelor’s Degree.
  • 3 to 5 years experience in a Provider Services position working with providers.
  • 5 to 10 years experience in the managed care/health insurance industry with demonstrated strengths in: knowledge of Plan policies and procedures related to provider complaint resolution, provider credentialing, provider billing and payment, provider incentive programs and other key State and Federal regulatory requirements related to providers, claim adjudication systems, provider file database requirements and relevant software applications; working independently and managing complex projects and programs both as an independent owner and team leader, training and mentoring skills, interacting at an executive level internally and externally.
  • Substantive Account Executive experience with high impact, high dollar, extremely visible and critical provider groups.
  • Medicaid experience required.
  • Hybrid role requiring 2 days in office and also must reside in Washington DC, Maryland or Virginia.