Category: Uncategorized

 
 

Position:

Quality and Risk Adjustment Manager

Position Summary:

The Quality and Risk Adjustment Manager, PHSO, is the subject matter expert and lead in developing and facilitating the implementation of new and existing healthcare Quality and Risk Adjustment strategies for a PHSO client. This position advises the client on quality and risk adjustment initiatives and provides support for program planning, patient campaigns, outreach tactics, and educational programs; conducts data collection; and reports and monitors key performance measurement activities for both quality and risk adjustment.

Job Description:

Primary Responsibilities

• Manage a comprehensive and coordinated Quality and Risk Adjustment strategy for our PHSO client by: developing data mining strategies; facilitating collection methodology and an effective quality and risk adjustment program; standardizing gap closure workflows and strategies; providing support for patient campaigns, and facilitating the development and implementation of Quality and Risk Adjustment programs for internal and external PHSO clients.
  
• Develop and maintain effective internal and external relationships through effective and timely communication.
  
• Synthesize and organize data, present information, and provide executive summary of material.
  
• Take initiative and action to respond, resolve and follow up regarding quality and risk adjustment with internal and external customers in a timely manner with outstanding customer service.
  
• Develop and maintain an expert level of knowledge of PHSO Quality metrics (such as MSSP, HEDIS, MA 5-Star, NQF) and MA, ACA, and Medicaid risk-based reimbursement methodologies.
  
• Maintain professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks and participating in professional societies.
  
• Oversee and improve the various quality and risk adjustment processes.
  
• Assist client with development of a comprehensive Risk Adjustment and Quality strategy and work plan, including workflow, outcome measures and performance evaluation.
  
• Facilitate the development of key quality and risk adjustment key performance indicators.
  
• Present quality performance results and findings regularly, including the overall measure performance, improvement strategies and tactics.
  
• Serve as a quality and risk adjustment subject matter expert for internal and external clients.
  
• Support activities of the PCV (Preventative Care Visit), patient outreach, and physician educational campaigns.
  
• Perform other duties as assigned.
  

Qualifications

• Bachelor’s degree; BSN, LPN, RHIA preferred
  
• 5+ years of experience in Quality Management and experience in HEDIS, MIPS/MSSP, and MA 5-Star, preferably in a health system or clinic setting
  
• 3+ years demonstrated management and team development skills
  
• 3+ years’ experience and proven success managing, implementing and auditing clinical quality programs
  
• 3+ years’ experience within healthcare, health plan, or health system, including payer, hospitals, Medicare/Medicaid, provider environment, or managed care
  
• Knowledge of Risk Adjustment Payment methodologies; understanding of CMS HCC, HHC, and Medicaid
  
• Medicare Advantage knowledge strongly preferred
  
• Proficiency with clinical data management and statistical quality tools
  
• Analytical and quantitative problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
  
• Ability to operate in a fast-paced and dynamic environment
  
• Excellent verbal, written, and interpersonal communication skills; ability to present in front of a group
  
• Excellent organizational capabilities with ability to work effectively as a team player
  
• Strong aptitude for critical thinking and demonstrated data skills
  
• Capable of meeting deadlines and executing projects with minimal supervision
  
• Willingness to acquire new knowledge from an unfamiliar domain
  
• Ability to manage multiple job functions, priorities, and deadlines under pressure with shifting priorities in an expedient and decisive manner
  
• Ability to collaborate and work with all professional levels, internally and externally
  
• Detail oriented
  
• Proficiency in Microsoft Office Programs including Word, PowerPoint, Excel, and Outlook
  

Working Conditions

• While performing the duties of this job, the employee works in normal office working conditions.
  

Disclaimer

• The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job duties and responsibilities.
  

Lumeris is an EEO/AA employer M/F/V/D.

Location:

Remote – MO

Time Type:

Full time

 
 

From <https://lumeris.wd1.myworkdayjobs.com/en-US/LC/job/Remote—MO/Quality-and-Risk-Adjustment-Manager_R0004035?mode=job&iis=Indeed.com&iisn=Indeed.com>

*Please Note: This position is open until filled. Application assessment will be ongoing and the hiring authority reserves the right to offer the position at any time during the recruitment process. It is to the applicant’s advantage to apply as early as possible. *

 
 

The ideal candidate for this position will have program management and/or consultative experience in health services, social services or Medicaid programs. 

 
 

Position Objective:

This position participates in the design and development of programs and contracts, and the daily oversight and management of them. This includes policy promulgation, developing strategic recommendations, contract development and federal negotiations for Cost Allocation Plan (CAP) design and implementation; program and contract monitoring, developing and maintaining program guidance, developing manuals and training materials, developing and conducting program training and presentations, and providing technical assistance. This position may assist other program managers in completing these or other activities.

 
 

This position is responsible for participating in management of the Washington State Courts Juvenile Service Divisions (WSCJSD) Medicaid Administrative Claiming (MAC) program. MAC programs are a state-federal partnership which provider reimbursement to government contractors for the time they spend supporting the Medicaid State Plan. MAC programs are authorized through a federally approved CAP which describes the program and the methodology used to determine eligible reimbursements. This position supports other MAC programs in the unit, as well as reimbursement contracts with state agencies. This position may be assigned and be directly responsible for specific components of these programs.

 
 

Some of what you will do:

• Responsible for using independent judgment and program subject matter expertise and knowledge to develop, write, and oversee all aspects of assigned MAC programs and reimbursement contracts including business requirements, policy promulgation, contract and CAP development, contract execution, claiming processes, program and contract monitoring, claim payment, writing and maintaining  program manuals, training materials, and developing provider and stakeholder training to ensure the HCA’s MAC time study and claiming processes are in compliance with federal guidelines.
  
• Demonstrate extensive knowledge and understanding of applicable state and federal rules and regulations; consults with the Centers for Medicare & Medicaid Services (CMS) as required.  Utilize expert analysis of new and emerging federal and state regulations to determine the impact or need to make changes to assigned MAC programs.
  
• Provide professional and technical subject matter expertise and guidance for developing, writing, implementing, and overseeing policies and procedures having statewide impact on assigned MAC programs and reimbursement contracts.
  
• Responsible for independent judgment and program subject matter expertise to provide professional and technical expertise and guidance, consultation and recommendations for the design, development, testing and use of the numerous processes, and methods involved in the time study, claim calculations, and other aspects of MAC programs and reimbursement contracts.
  
• Designing, developing, writing, implementing, evaluating and improving monitoring tools and processes.
  
• Represent HCA and the state in negotiations with state and federal partners on major, substantive, and innovative MAC program methods and related federal law impacting HCA.
  
• Provide related MAC program and time study system training to external stakeholders, internal managers and work units as needed.
  
• Plan, design, develop, write, schedule, test, implement, evaluate and improve program policy and procedures for assigned MAC program business requirements and operational processes.
  
• Plan, design, develop, write, schedule, implement, evaluate and improve on-going training relating to program modifications needed to ensure assigned MAC programs are in compliance with federal guidelines.
  

 
 

Here is what we are looking for (Required Qualifications):

A Master’s degree with major study in public health, public administration, social work, or closely related field and two years of supervisory or consultative experience in health services, social services or Medicaid programs.

(Two additional years of qualifying experience will substitute for the required Master’s degree provided a Bachelor’s degree has been achieved)   

OR

A Bachelor’s degree and two years of experience administrating one or more statewide policies or programs of an agency or agency subdivision. 

OR

Additional qualifying experience may substitute year for year, for required education.

 
 

Desirable/Preferred Qualifications:

Communicate and work effectively with a broad range of program and fiscal managers and staff, contractors, and their agents, legislators and legislative staff, and other stakeholders.

 
 

Highly capable of working in multiple environments such as remotely and in office.

 
 

Highly capable of mastering virtual platforms and utilizing multiple different platforms on a daily basis.

 
 

Coordinate and track multiple, diverse activities and work independently with limited supervision.

 
 

Strong ability to complete assignments with limited or ambiguous guidance.

 
 

Make clear, understandable written, graphic and verbal directions.

 
 

Highly independent, self learner, with ability to easily transition between group and independent assignments.

 
 

Make presentations consisting of cost/benefit, process improvement and similar analyses and policy recommendations; capable of learning new analytics tools.

 
 

Envision and develop timely program plans and monitoring of results.

 
 

Write clear and concise reports.

 
 

About the HCA: 

The Washington State Health Care Authority (HCA) is committed to whole-person care, integrating physical health and behavioral health services for better results and healthier residents.

 
 

HCA purchases health care for more than 2.5 million Washington residents through Apple Health (Medicaid), the Public Employees Benefits Board (PEBB) Program, and the School Employees Benefits Board (SEBB) Program. As the largest health care purchaser in the state, we lead the effort to transform health care, helping ensure Washington residents have access to better health and better care at a lower cost.

 
 

What we have to offer:

• Meaningful work with friendly co-workers who care about those we serve Voices of HCA 
  
• A clear agency mission that drives our work and is person-centered HCA’s Mission, Vision & Values
  
• A healthy work/life balance, including alternative/flexible schedules and mobile work options.
  
• Infants in the workplace Infants at the Workplace Video
  
• A great total compensation and benefit package WA State Government Benefits
  
• A safe, pleasant workplace in a convenient location with restaurants, and shopping nearby. 
  
• Tuition Reimbursement
  
• And free parking! 
  

 
 

About Olympia and Washington State:

Washington State offers a total work/life package of pay, benefits, flexibility, and workplace opportunities to help you get the most out of your career and out of life. Washington State is a great place to work, play, and be a part of a community, offering quality of life that is unsurpassed. From the high energy urban center of Seattle, one of the nation’s top ranked cities, to the more relaxed pace of our rural communities, Washington’s distinctive Northwest lifestyle blends a progressive, creative culture with a casual nature.

 
 

How to Apply: 

 Only candidates who reflect the minimum qualifications on their NEOGOV profile will be considered.  Failure to follow the application instructions below may lead to disqualification.  To apply for this position you will need to complete your profile and attach:

• A cover letter that specifically addresses how you meet the qualifications for this position. 
  
• Current resume 
  
• Three professional references
  

 
 

 Washington State is an equal opportunity employer. Persons with disabilities needing assistance in the application process, or those needing this job announcement in an alternative format may call the Human Resources Office at 360.725.1761 or email Dennis.Lienemann@hca.wa.gov.

 
 

 *Prior to a new hire, a background check including criminal record history will be conducted. Information from the background check will not necessarily preclude employment but will be considered in determining the applicant’s suitability and competence to perform in the position. *

 
 

From <https://www.governmentjobs.com/careers/washington/jobs/2931459/medicaid-program-manager-maps2-mpoi>

 
 

Qualifications

• Bachelor’s (Preferred)

About Monogram Health

We are dedicated to improving the well-being, quality of life and health outcomes for our patients by partnering with the nation’s leading kidney specialists to provide transformative kidney care. Monogram Health supports patients suffering from Chronic Kidney Disease and End Stage Renal Disease by forming deep rooted relationships and preparing them both emotionally and physically for the challenges of managing Kidney Disease. Monogram Health uses next generation artificial intelligence algorithms to predict necessary and timely care to promote the delay of Kidney Disease progression, seamless transitions to dialysis and/or pre-emptive kidney transplant as well as to optimize our patients’ health outcomes once on dialysis.

Position: SNP Program Manager/Director

The Special Needs Plan (SNP) (Duals), Program Manager is required to carefully monitor the performance and adherence to the Centers for Medicare and Medicaid Services (CMS) regulatory requirements based on an approved Model of Care (MOC).

In this role, the individual will be expected to provide a high level of program and product specific subject matter expertise. He or she will be responsible for intensive oversight of the program to ensure performance, quality, regulatory adherence and audit readiness.

The SNP Program Director reports directly to the VP, Enterprise Programs and works closely with the Clinical and Market Operations, and other teams across the organization.

Roles and Responsibilities

· Develop and implement programmatic requirements to meet SNP MOC requirements

· Oversee implementation and monitoring of Interdisciplinary Care Team (ICT) requirements and outcomes

· Continuous monitoring of compliance of SNP SLAs

· Continuous evaluation of effectiveness of SNP program

· Complete mock audits to ensure audit preparedness

· Support Monogram as necessary with any tasks required to deliver excellent personalized kidney care and perform all other duties as assigned

· Uphold the mission and values of Monogram Health in all aspects of your role and activities

Position Requirements

· Phoenix, AZ or Nashville, TN; office-based

· Bachelor’s degree from a four-year college

· 3+ years’ experience with program management, project management, or similar experience

· 3+ years’ experience working for a health plan, and/or vendor contracting with health plans delegated for services

· 3+ years’ experience with Medicare SNP programmatic requirements

· Detail oriented, excellent prioritization, and time management skills

· Expertise partnering with internal departments to drive collaboration and results

· Highly proficient in Microsoft Excel, Word, and Powerpoint

· Experience working in high-growth environment preferred

· Valid driver’s license

Benefits

· Opportunity to work in a dynamic, fast-paced and innovative care management company that is transforming the delivery of kidney care

· Competitive salary, commensurate with experience

· Comprehensive medical, dental, vision and life insurance

· Flexible paid leave & vacation policy

· 401(k) plan with matching contributions

At Monogram Health we believe in fostering an inclusive environment in which employees feel encouraged to share their unique perspectives, leverage their strengths, and act authentically. We know that diverse teams are strong teams, and welcome those from all backgrounds and varying experiences.

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Professional development assistance
• Vision insurance

Schedule:

• Monday to Friday

COVID-19 considerations:
We work from the office. We follow CDC guidelines to keep our employees and program members healthy and safe.

Education:

• Bachelor’s (Preferred)

Work Location:

• One location

This Company Describes Its Culture as:

• Aggressive — competitive and growth-oriented
• Outcome-oriented — results-focused with strong performance culture

Company’s website:

• www.monogramhealth.com

Work Remotely:

• No

COVID-19 Precaution(s):

• Remote interview process
• Personal protective equipment provided or required
• Social distancing guidelines in place
• Virtual meetings
• Sanitizing, disinfecting, or cleaning procedures in place

 
 

Clipped from: https://www.indeed.com/viewjob?ad=-6NYlbfkN0DVARdmeX_ROF5pf7lvQRg4TirPJSv0nNW_kyMAkJAkKoCvgGq4rngn8KXdTaF7DkTQ5IcrvwUPsrA0eo6lW5FaKAfGUSs-smsC8lmA-7QL6eNckI4khAwxlSjvSSVZmTJjs-GBn5ahhz-xHbCjDrT2CU6Blb3MRgt-VkWtH9f-QQcn5EoM2gdp47UZk0KNxn4mHglT3BnRK9rXAlO4ogb5HuapzbQi16JnvekQQOnuPM3_C1rIJUwk3H67M6341t_4tE0oJApoW8h1oM2U6B6hTdnGYsGMuyF-tTibjMW2vuFeK4G14nFxNdk0l7X9Nef4xsKOKjoLC6cdY7q1EBlA&adid=362652666&cmp=Monogram-Health%2C-Inc&from=iaBackPress&jk=4875868139cc68b9&pub=4a1b367933fd867b19b072952f68dceb&sjdu=QwrRXKrqZ3CNX5W-O9jEvWKcSsYF_EXfiEZCGQoVTCioUiBmHTwb00oP3m5W6wtNWklT6SCqiLegnXZwahzkzWxlEcfPSf3pduWI7aTmsDIgwc2TLryA3G7Rb4K_E8hJKCZkvS5jaLqBzT5tazmTdA&t=Snp%20Health%20Plan%20Director&tk=1erubfk32u4pi800&vjs=3

 
 

Department of Health And Human Services

Center for Medicare and Medicaid Innovation (CMMI)

Summary

This position is located in the Department of Health & Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Center for Medicare and Medicaid Innovation (CMMI), Seamless Care Models Group (SCMG).


As a Health Insurance Specialist (Program Policy), GS-0107-12, you will perform program policy work related to national health insurance programs, such as Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP).

Learn more about this agency

Responsibilities

• Interpret statute and develop Federal regulations, policy statements, models and other program guidance.
• Review and evaluate proposed, modified, or new legislation and regulations to assess the impact on CMS programs.
• Establish and maintain relationships with key officials and groups within and outside CMS to resolve problems pertaining to program policies.
• Prepare and coordinate a variety of written products, including position papers and briefing materials for senior officials to use as background information on program policy related activities.

Travel Required

Occasional travel – You may be expected to travel 10% for this position.

Supervisory status

No

Promotion Potential

12

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Requirements

Conditions of Employment

• You must be a U.S. Citizen or National to apply for this position.
• You will be subject to a background and suitability investigation.

Qualifications

ALL QUALIFICATION REQUIREMENTS MUST BE MET BY THE CLOSING DATE OF THIS ANNOUNCEMENT.

In order to qualify for the GS-12, you must meet the following: You must demonstrate in your resume at least one year (52 weeks) of qualifying specialized experience equivalent to the GS-11 grade level in the Federal government, obtained in either the private or public sector, to include:
(1) Researching and analyzing health insurance program policy issues (for Medicare, Medicaid or private health insurance companies) in order to make policy recommendations;
(2) Developing regulations, manuals, program guidelines, operational guidance documents or instructions to communicate health insurance program policies for the Medicare, Medicaid or private health insurance companies ; AND
(3) Presenting findings or recommendations to stakeholders based on analysis of health insurance programs.


Substitution of Education for Experience: There is no substitution of education to meet the specialized experience requirement at the GS-12 grade level.


Combination of Experience and Education: There is no combination of experience and education to meet the specialized experience requirement at the GS-12 grade level.


Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religious; spiritual; community, student, social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.


Click the following link to view the occupational questionnaire: https://apply.usastaffing.gov/ViewQuestionnaire/11002921

Education

Additional information

Bargaining Unit Position: Yes

Tour of Duty: Flexible

Recruitment/Relocation Incentive: Not Authorized

Financial Disclosure: Not Required


CMS employees currently participating in 100% Full-Time Telework Program may be eligible to remain in the program. If an employee in this program is selected, the pay will be set in accordance with the locality pay for the applicable duty station. The listed salary range reflects the locality pay assigned to the duty location(s) listed in the vacancy announcement. For more information about pay based on locality, please visit the Office of Personnel Management (OPM) Salaries & Wages Page.


The Interagency Career Transition Assistance Plan (ICTAP) and Career Transition Assistance Plan (CTAP) provide eligible displaced federal employees with selection priority over other candidates for competitive service vacancies. To be qualified you must submit the required documentation and be rated well-qualified for this vacancy. Click here for a detailed description of the required supporting documents. A well-qualified applicant is one whose knowledge, skills and abilities clearly exceed the minimum qualification requirements of the position. Additional information about ICTAP and CTAP eligibility is on OPM’s Career Transition Resources website at www.opm.gov/rif/employee_guides/career_transition.asp.


Additional Forms REQUIRED Prior to Appointment:

• Optional Form 306, Declaration of Federal Employment and the Background/Suitability Investigation – A background and suitability investigation will be required for all selectees. Appointment will be subject to the successful completion of the investigation and favorable adjudication. Failure to successfully meet these requirements may be grounds for appropriate personnel action. In addition, if hired, a reinvestigation or supplemental investigation may be required at a later time. If selected, the Optional Form 306 will be required prior to final job offer. Click here to obtain a copy of the Optional Form 306.
• Form I-9, Employment Verification and the Electronic Eligibility Verification Program – CMS participates in the Electronic Employment Eligibility Verification Program (E-Verify). E-Verify helps employers determine employment eligibility of new hires and the validity of their Social Security numbers. If selected, the Form I-9 will be required at the time of in-processing. Click here for more information about E-Verify and to obtain a copy of the Form I-9.
• Standard Form 61, Appointment Affidavits – If selected, the Standard Form 61 will be required at the time of in-processing. Click here to obtain a copy of the Standard Form 61.

If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application.

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How You Will Be Evaluated

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

If you meet the minimum qualifications and education requirements for this position, your application and responses to the online occupational questionnaire will be evaluated under Category Rating and Selection procedures for placement in one of the following categories:

• Best Qualified – for those who are superior in the evaluation criteria
• Well Qualified – for those who excel in the evaluation criteria
• Qualified – for those who only meet the minimum qualification requirements

The Category Rating Process does not add veterans’ preference points or apply the “rule of three” but protects the rights of veterans by placing them ahead of non-preference eligibles within each category. Veterans’ preference eligibles who meet the minimum qualification requirements and who have a compensable service-connected disability of at least 10 percent will be listed in the highest quality category (except in the case of professional or scientific positions at the GS-09 level or higher).


Once the announcement has closed, your online application, resume, transcripts and CMS required documents will be used to determine if you meet eligibility and qualification requirements listed on this announcement. If you are found to be among the top qualified candidates, you will be referred to the selecting official for employment consideration. Please follow all instructions carefully. Errors or omissions may affect your rating.


Your qualifications will be evaluated on the following competencies (knowledge, skills, abilities and other characteristics):

• Health Insurance
• Oral Communication
• Policy Analysis
• Written Communication

This is a competitive vacancy announcement advertised under Delegated Examining Authority. Selections made under this vacancy announcement will be processed as new appointments to the civil service. Current civil service employees would therefore be given new appointments to the civil service; however, benefits, time served and all other Federal entitlements would remain the same.


Additional selections may be made from this announcement for similar positions within CMS in the same geographical location. For Central Office vacancies, the “same geographical location” includes Baltimore, Maryland; Bethesda, Maryland; and Washington, D.C.

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Background checks and security clearance

Security clearance

Not Required

Drug test required

No

Position sensitivity and risk

Moderate Risk (MR)

Trust determination process

Credentialing, Suitability/Fitness

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Required Documents

The following documents are REQUIRED:


1. Resume
showing relevant experience; cover letter optional. Your resume must indicate your citizenship and if you are registered for Selective Service if you are a male born after 12/31/59. Your resume must also list your work experience and education (if applicable) including the start and end dates (mm/dd/yy) of each employment along with the number of hours worked per week. For work in the Federal service, you must include the series and grade level for the position(s). Your resume will be used to validate your responses to the assessment tool(s). For resume and application tips visit: https://www.usajobs.gov/Help/faq/application/documents/resume/what-to-include/

2. CMS Required Documents (e.g., SF-50, DD-214, SF-15, etc.). Required documents may be necessary to be considered for this vacancy announcement. Click here for a detailed description of the required documents. Failure to provide the required documentation WILL result in an ineligible rating OR non-consideration.


3. College Transcripts. Although this position does not require a degree, you may substitute college credit in whole, or in part, for experience at specified grade levels. You must submit a copy of your transcript at the time of application in order to substitute your education for the required experience. If you do not submit a transcript, your education will not be considered in determining your qualifications for the position. You may submit an unofficial transcript or a list of college courses completed indicating course title, credit hours, and grades received. An official transcript is required if you are selected for the position.


College Transcripts and Foreign Education: Applicants who have completed part or all of their education outside of the U.S. must have their foreign education evaluated by an accredited organization to ensure that the foreign education is comparable to education received in accredited educational institutions in the U.S. For a listing of services that can perform this evaluation, visit the National Association of Credential Evaluation Services website. This list, which may not be all inclusive, is for informational purposes only and does not imply any endorsement of any specific agency.


PLEASE NOTE: A complete application package includes the online application, resume, transcripts (if qualifying through education substitution or a combination of education and experience) and CMS required documents. Please carefully review the full job announcement to include the “Required Documents” and “How to Apply” sections. Failure to submit the online application, resume, transcripts (if applicable) and CMS required documents, will result in you not being considered for employment.

If you are relying on your education to meet qualification requirements:

Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.

Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.

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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. Learn 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.

• Help

How to Apply

Your complete application package, as described in the “Required Documents” section, must be received by 11:59 PM ET on 01/21/2021 to receive consideration.


IN DESCRIBING YOUR WORK EXPERIENCE AND/OR EDUCATION, PLEASE BE CLEAR AND SPECIFIC REGARDING YOUR EXPERIENCE OR EDUCATION.


We strongly encourage applicants to utilize the USAJOBS resume builder in the creation of resumes. Please ensure EACH work history includes ALL of the following information:

• Official Position Title (include series and grade if Federal job)
• Duties (be specific in describing your duties)
• Employer’s name and address
• Supervisor name and phone number
• Start and end dates including month, day and year (e.g. June 18, 2007 to April 05, 2008)
• Full-time or part-time status (include hours worked per week)
• Salary

Determining length of general or specialized experience is dependent on the above information and failure to provide ALL of this information WILL result in a finding of ineligible.

• To begin, click Apply to access the online application. You will need to be logged into your USAJOBS account to apply. If you do not have a USAJOBS account, you will need to create one before beginning the application.
• Follow the prompts to select your resume and/or other supporting documents to be included with your application package. You will have the opportunity to upload additional documents to include in your application before it is submitted. Your uploaded documents may take several hours to clear the virus scan process.
• After acknowledging you have reviewed your application package, complete the Include Personal Information section as you deem appropriate and click to continue with the application process.
• You will be taken to the online application which you must complete in order to apply for the position. Complete the online application, verify the required documentation is included with your application package, and submit the application.

To verify the status of your application, log into your USAJOBS account (https://my.usajobs.gov/Account/Login), all of your applications will appear on the Welcome screen. The Application Status will appear along with the date your application was last updated. For information on what each Application Status means, visit: https://www.usajobs.gov/Help/how-to/application/status/.


This agency provides reasonable accommodation to applicants with disabilities. If you need a reasonable accommodation for any part of the application or hiring process, please send an email to Amanda.sullivan@cms.hhs.gov. The decision to grant reasonable accommodation will be made on a case-by-case basis.


Commissioned Corps Officers (including Commissioned Corps applicants that are professionally boarded) who are interested in applying for this position must send their professional resume (not PHS Curriculum Vitae) and cover letter to CMSCorpsJobs@cms.hhs.gov in lieu of applying through this announcement. The cover letter should specifically explain how you are qualified for this position and draw specific attention to your resume that demonstrates these qualifications. In the subject line of your e-mail please include only the Job Announcement Number. In the body of your e-mail please include your current rank name and serial number. Failure to provide this information may impact your consideration for this position.

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Agency contact information

Amanda Sullivan

Email

Amanda.sullivan@cms.hhs.gov

Address

Center for Medicare and Medicaid Innovation
7500 Security Blvd
Woodlawn, MD 21244
US

Learn more about this agency

Next steps

Once your online application is submitted, you will receive a confirmation notification by email. Your application will be evaluated to determine your eligibility and qualifications for the position. After the evaluation is complete, you will receive another email notification regarding the status of your application.


Within 30 business days of the closing date,01/21/2021, you may check your status online by logging into your USAJOBS account (https://my.usajobs.gov/Account/Login). We will update your status after each key stage in the application process has been completed.

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• Fair & Transparent

The Federal hiring process is setup to be fair and transparent. Please read the following guidance.

Equal Employment Opportunity Policy

The United States Government does not discriminate in employment on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an employee organization, retaliation, parental status, military service, or other non-merit factor.

• Equal Employment Opportunity (EEO) for federal employees & job applicants

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Reasonable Accommodation Policy

Federal agencies must provide reasonable accommodation to applicants with disabilities where appropriate. Applicants requiring reasonable accommodation for any part of the application process should follow the instructions in the job opportunity announcement. For any part of the remaining hiring process, applicants should contact the hiring agency directly. Determinations on requests for reasonable accommodation will be made on a case-by-case basis.

A reasonable accommodation is any change to a job, the work environment, or the way things are usually done that enables an individual with a disability to apply for a job, perform job duties or receive equal access to job benefits.

Under the Rehabilitation Act of 1973, federal agencies must provide reasonable accommodations when:

• An applicant with a disability needs an accommodation to have an equal opportunity to apply for a job.
• An employee with a disability needs an accommodation to perform the essential job duties or to gain access to the workplace.
• An employee with a disability needs an accommodation to receive equal access to benefits, such as details, training, and office-sponsored events.

You can request a reasonable accommodation at any time during the application or hiring process or while on the job. Requests are considered on a case-by-case basis.

Learn more about disability employment and reasonable accommodations or how to contact an agency.

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Legal and regulatory guidance

• Financial suitability
  
• Social security number request
• Privacy Act
• Signature and false statements
• Selective Service
• New employee probationary period

 
 

Clipped from: https://www.usajobs.gov/GetJob/ViewDetails/588778500

 
 

Position Description:
 

Mathematica applies expertise at the intersection of data, methods, 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.

Mathematica is searching for professionals with experience generating insights from data on Medicaid policy and programs at either the state or federal level. In particular, we are looking for individuals who can apply data analytics to support current and emerging work across any number of areas related to monitoring and improving Medicaid programs such as: Value-based purchasing and alternative payment models, enrollment trends, measures of delivery and quality of services for beneficiaries, and to discern outcomes of innovative programs and policies.

The successful candidate will join our group of over 400 health policy professionals, including staff with degrees in data analytics, public health, public policy, economics, behavioral or social sciences, economics, and other relevant disciplines. We offer our employees a stimulating team-oriented work environment, competitive salaries, and a comprehensive benefits package, as well as the advantages of employee ownership.
 

Duties of the position:

• Participate actively and thoughtfully in multidisciplinary teams, drawing on your past experience with Medicaid programs
• Help conduct research and technical assistance projects on topics related to state and federal Medicaid policy
• Apply rigorous analytic thinking to the collection and interpretation of quantitative data including analysis of Medicaid administrative data
• Bring creative ideas to the development of proposals for new projects
• Author project reports, memos, technical assistance tools, issue briefs, and webinar presentations
• Contribute to the growth, expertise, and institutional knowledge of staff working in the Medicaid area

Position Requirements:
 

Qualifications:

• 3-8 years of experience working in health policy or health research, with a substantial portion of that time related to some aspect of the Medicaid program at the state or federal level
• Masters or doctoral degree or equivalent experience in data analytics, public health, public policy, economics, behavioral or social sciences, economics, or other relevant disciplines
• Demonstrated ability at modeling program outcomes would be ideal
• Strong foundation in quantitative methods and a broad understanding of health policy issues
• Excellent written and oral communication skills, including an ability to explain observations and findings to diverse stakeholder audiences including program administrators and policymakers
• Demonstrated ability to provide task leadership and coordinate the work of multidisciplinary teams

Strong organizational skills and high level of attention to detail; flexibility to lead and manage multiple priorities, sometimes simultaneously, under deadlines

To apply, please submit a cover letter, resume, writing sample, and salary expectations at the time of your application.

This position offers an anticipated annual base salary of $90,000 – $140,000. This position may be eligible for a discretionary bonus based on company and individual performance.

Available Locations: Washington, DC; Princeton, NJ; Cambridge, MA; Woodlawn, MD; Ann Arbor, MI; Chicago, IL; Oakland, CA; Seattle, WA

Various federal agencies with whom we contract require that staff successfully undergo a background investigation or security clearance as a condition of working on a project. If you are assigned to such a project, you will be required to obtain the requisite security clearance.

 
 

Clipped from: https://careers.mathematica.org/job/-/-/727/3773820176?source=Indeed.com&sourceType=PREMIUM_POST_SITE

 
 

 
 

 

• Everywhere you turn, you can feel it.  There’s an immeasurable level of enthusiasm at East Boston Neighborhood Health Center (EBNHC), one of the largest community health centers in the country.  From the nurses and physicians on the front line of patient care, to the managers who shape our policies, to the customer service representatives who keep our facilities running smoothly – everyone here has a role in making medicine better.
  Interested in this position?  Apply on-line and create a personal candidate account!
  Current Employees of EBNHC – Please use the internal careers portal to apply for positions.
  To learn more about working at EBNHC and our benefits, check out our Careers Page at careers.ebnhc.org.
  Time Type:
  Full time
  Department:
  Quality
  All Locations:
  East Boston
  Description:
  EBNHC is a member of Community Care Cooperative (C3), an organization formed by 13 Federally Qualified FQHCs located throughout the Commonwealth of Massachusetts. C3, a 501(c)(3) non- profit Accountable Care Organization (ACO), is taking responsibility for managing the cost and quality of health care for MassHealth enrollees. C3’s vision is transforming the health of underserved communities. As a member of C3, EBNHC is uniquely positioned to be a true innovator in meeting quality goals and reducing cost of care for a large Medicaid population.
  The Population Health Manager (PHM) will be responsible for driving value based care initiatives at EBNHC. Partnering closely with EBNHC leadership, providers, and staff, you will integrate C3’s clinical programs and resources into the practice workflows with the intent to optimize the enrollee experience, and positively impact provider engagement and quality of care provided.
  Education
  
• Bachelor’s Degree
  Experience
  
• 5+ years of leadership experience in practice management, provider relations and project management
  

 
 

<https://ebnhc.wd1.myworkdayjobs.com/EBNHC/job/East-Boston/Quality-Improvement-and-Population-Health-Manager_R0002612?source=Indeed>

Description

Job Summary: Oversees network and analytics strategy and execution for Delta Dental’s government business, including delivery of Medicaid and Medicare population health strategies. Directs matrix-oriented delivery model that ensures enterprise is delivering government-specific solutions unique to federal and state regulations.

Primary Job Responsibilities

1. Directs the daily activities of the team responsible for government programs network management, clinical performance, social determinants of health (SDOH), and the application of data analytics in maintaining optimal results.

2. Develops, recommends, and implements short and long term action plans in order to ensure the achievement of business unit goals.

3. Serves as leader in the development and monitoring of Medicare and Medicaid networks.

4. Establishes analytics function within the government programs business unit that is integrated into decision-making.

5. Communicates with and advises executive management on the planning and activities of government business.

6. Create and maintains governance of operational issues pertaining to government programs.

7. Supports business development efforts and serves as primary point of contact for network issues with clients.

8. Interviews, hires, evaluates, manages, and develops staff in order to ensure accountability for the achievement of departmental and individual goals and objectives.

Perform other related assigned duties as necessary to complete the Primary Job Responsibilities as described above.

Location

Delta Dental MI-Farm Hills-DDFH

Requirements

Position requires a bachelor’s degree with an emphasis in business administration or a related field, seven years of experience in Medicaid, Medicare, insurance and / or clinical operations, and three years of leadership experience.

Position requires experience in provider contract network development, management, optimization and familiarity of various provider compensation models including fee-for-service, capitation, value-based reimbursement, risk sharing, etc.

Position also requires advanced knowledge of the managed care industry, strong verbal and written communication skills; strong interpersonal skills; and the ability to resolve complex problems using independent judgment.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

 
 

Clipped from: https://recruiting.adp.com/srccar/public/RTI.home?c=1214201&d=TRI&rb=INDEED&r=5000670111306#/

Molina Healthcare Job ID 2006424

Apply Now

Job Description
Job Summary
This role will have a heavy focus on leading our reporting and analytics in A&G. Responsibilities include leading an audit and analytics team, managing/improving quality reporting, analyzing trends and ad hoc reporting. Ideal candidates would have experience in Appeals & Grievances, Medicaid reporting and analytics and reporting.

Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member complaints and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid.

Knowledge/Skills/Abilities

• Reviews and analyzes collective grievance and appeals data along with audit results on unit’s performance; analyzes and interprets trends and prepares reports that identify root causes of member/provider dissatisfaction
• Recommends and implements process improvements to achieve member/provider satisfaction of operational effectiveness/efficiencies.
• Leads, organizes, and directs the activities of the Appeals & Grievance unit that is responsible for member and provider Appeals and Grievances for Marketplace. 
• Provides direct oversight, monitoring and training of provider dispute and appeals units to ensure adherence with Marketplace standards and requirements.
• Trains grievance and appeals staff and other departments within Molina Marketplace on early recognition an timely routing of member complaints
• Trains provider dispute resolution unit on Marketplace standards and requirements, including the proper use of the Molina Appeals and Grievance system.

Job Qualifications

• Strong claims background
• Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing).
• Management of 100+ employee’s experience.
• 7 years’ experience in healthcare claims review and/or member appeals and grievance processing/resolution, including 2 years in a manager role.
• Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB92, 2 years supervisory/management experience with appeals/grievance processing within a managed care setting.

Required Education
Associate’s Degree or 4 years of grievance and appeals experience.

Required License, Certification, Association

None

Preferred Education
Bachelor’s Degree

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

About Us

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Job Type: Full Time Posting Date: 01/11/2021

 
 

Clipped from: https://careers.molinahealthcare.com/job/-/-/21726/18446736?src=Indeed

The Senior Enrollment Medicaid Specialist will be the first source of job-related information and will support and assist with tasks/training relating to Integrated Products (IP), Management Services Organizations (MSO), Marketing Specialists and the PHSP lines of business within enrollment and retention. This includes, but is not limited to train/teach product, process and policy information at the onset of the hiring process as well as on a continuous basis. Being proficient in their ability to communicate with impact, apply critical thinking and possess leadership skills. The Senior Enrollment Medicaid Specialist will act as a role model and provide continuous coaching and feedback to the team. They will also assist and work closely with the Quality Performance Team in monitoring the quality of application submitted, track enrollment performance behaviors, identify areas for improvement and recommend to the proper Management Team. Senior Enrollment Medicaid Specialist will develop talent by identifying the Specialist strengths and suggest them for project work.

• Interprets product, procedural and regulatory information, and assists with the development of training curricula to provide field staff with available services
• Administer new hire training and refresher training to the Marketing Specialists, Relationship Coordinators, and Enrollment Medicaid Specialist teams
• Participates in the development, implementation, and updates provided by Healthfirst to ensure departmental compliance
• Due to the nature of additional responsibility, their home visits will be substantially lower than any of the other Enrollment Medicaid Specialists but will be required to make visits when needed
• Provide expertise and customer service support to the teams and consumers.
• Conduct observational field visits and provide guidance and support to the teams
• Aids in increasing individual and team effectiveness by creating and distributing training resources, learning aids and process documentation to learners
• Prepares and maintains reports/records on training program attendance and programs offered
• Participates in any training-related projects as scheduled or otherwise directed by the Director of Training and is expected to provide viable input for all projects and ensure that all assignments are completed with quality and accuracy
• Serve as the subject matter expert in all services offered
• Liaison between Local Department of Social Services, New York Medicaid Choice, and internal department
• Assist in the scheduling of staff for training
• Must have excellent listening, as well as written and oral communication skills
• Must have strong interpersonal skills and professional attitude

Minimum Qualifications:

• Associate’s Degree
• Proficiency in navigating the Internet and multitasking with multiple software/electronic documentation systems simultaneously
• Excellent written communication and the ability to document grammatically correct notes and correspondence
• Ability to be independent in making sound decisions and proactive in identifying and implementing process improvements
• Aptitude for using a fast-paced proactive vs. reactive approach, maneuvering multiple tasks simultaneously including seamlessly changing priorities
• Establish credibility and trust along with positive and affable working relationships with internal and external clients

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement

All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst.  Healthfirst will never ask you for money during the recruitment or onboarding process.

 
 

Clipped from: https://careers.healthfirst.org/us/en/job/R009061/Sr-Enroll-Medicaid-Spec?mode=job&iis=Job+Board&iisn=Indeed.com