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Other duties include, but may not be limited to, an overview of coding practices and clinical documentation, grievance and appeals processes (including pharmacy), and reviews for DME, genetic testing, etc.
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Represent clients in communications and negotiations with MassHealth and Health Connector officials, health care providers, managed care entities, and in appeals before the Office of Medicaid Board of Hearings.
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Job InformationHumanaRegional VP, Operations IL MedicaidinChicagoIllinoisDescriptionHumana's Illinois Medicaid, Operations Officer (COO) will be responsible for the strategic development and oversight of operations for Huma.
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Oversees coding practices and clinical documentation, grievance, and appeals processes (including pharmacy), and conducts reviews for durable medical equipment (DME), genetic testing, etc. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
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Learns Medicaid requirements and understands how to operationalize this knowledge in their daily work in their assigned (Southwest cluster which currently serves Louisiana and Oklahoma) Experience working with Medicaid Enrollees, providers, and stakeholders in a clinical or administrative setting.
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Medical Director - Southwest Medicaid. Become a part of our caring community and help us put health first. May speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, which may include an understanding of Humana processes and a focus on collaborative business relationships, value-based care, population health, or disease or care management.
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Provide support to Medicaid markets within the region, aiding in case review, peer to peer and appeals as needed. Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope.
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Work includes computer-based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management, with clinical scenarios arising from outpatient, inpatient, or post-acute care environments.
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Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Experience in utilization management review and case management in a health plan setting.
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The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. Experience with accreditation process (NCQA) Uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, or requested site of service should be authorized, with all work occurring within a context of regulatory compliance and assisted by diverse resources, which may include national clinical guidelines, state policies, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other reference sources.
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Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion.
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Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
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We also provide free language interpreter services. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work.
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Conducts discussions with external physicians by phone to gather additional clinical information or discuss determinations through the peer-to-peer process, and in some instances, these may require conflict resolution skills.
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The Appeals and Grievance Coordinator will coordinate, process, and document all aspects of member appeals and grievances, as well as provider appeals across all our product offerings (Commercial, Medicaid and Medicare.
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