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Utilization Management, Claims, Pharmacy Operations, Compliance, FDR oversight activities, Quality Management, Care Management, and/or Grievances and Appeals. The Compliance Auditor I is responsible to perform routine audit and monitoring activities of internal health plan departments and external Plan delegates to ensure compliance with Medi-Cal and Medicare regulatory and contractual requirements, and operational plan requirements.
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The Reimbursement Analyst is responsible for providing cost report preparation, cost report appeals, audit preparation and other duties related to the regulatory reimbursement services of Dignity Health.
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JOB SUMMARY At Houston Methodist, the Manager Revenue Cycle position is responsible for the daily management of the staff and operations for one or more of the following areas of Revenue Cycle, to include but not limited to: insurance billing, collections, patient account resolution, appeals/denials, customer service, cash applications, revenue integrity, etc.
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The Manager oversees the resolution of member appeals and grievances for all product lines (Medi-Cal, Medi-Cal Direct, Medicare, PASC-SEIU and L.A. Care Covered) in a manner consistent with regulatory requirements from the Department of Managed Health Care, Department of Health Care Services, Centers for Medicare & Medicaid Services, as well as requirements from the National Committee on Quality Assurance (NCQA) and L.A. Care policies and procedures.
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Areas of responsibility include charge capture, charge reconciliation, charge maintenance CDM pricing strategy, charge edits, clinical denials, RAC audits, revenue cycle regulatory monitoring, and multidisciplinary clinical, operational, and financial revenue practice teams.
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Minimum of four years of administrative support experience in a health care organization required Knowledge of DOH and CMS Grievance and Appeals regulatory requirements and procedures for ensuring compliance preferred Proficient PC skills, including MS Excel, Word, and Access required Knowledge of Facets system preferred.
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Michigan Medicine Finance is seeking a reimbursement analyst to provide support for cost report preparation, cost report appeals, audit preparation, revenue recognition, ad-hoc reporting, and other duties related to the regulatory reimbursement services of Michigan Medicine and it’s affiliates.
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Analyze and complete Medicare, Medicaid, Tricare and Blue Cross cost reports, settlements, audits and appeals and maintain all documentation. Michigan Medicine Finance serves as the central finance group for Michigan Medicine and is comprised of six functional areas: Clinical Financial Planning & Analysis, Enterprise Financial Reporting & Forecasting, Academic Financial Planning & Analysis, Reimbursement, Medical School Finance, and Financial Systems.
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The incumbent supports the General Counsel in providing legal advice and counsel on such matters as federal and state regulatory compliance, ethics, Freedom of Information Law requests, corporate governance, and legislation.
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Under the direction of the Disputes Technology & Services (DTS) practice group leader and DTS Paralegal Manager, the Energy and Environmental Regulatory Paralegal is a highly skilled, objective-oriented individual who utilizes a combination of practical experience and cutting-edge technology in a collaborative environment to provide Firm clients and attorneys with creative and cost-efficient solutions.
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Gathers pertinent information regarding the grievances and appeals received, including, but not limited to, member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal, or supplemental information required to evaluate grievances and appeals within regulatory requirements.
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Prepares reports on grievance and appeals as required by regulatory agencies, NCQA standards, and Plan management. Familiarity with DMHC, DHS, CMS, and other regulatory agency standards related to appeals and grievances.
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Demonstrated knowledge of utilization management, care management and grievance and appeals regulatory and accreditation requirements. Provide subject matter expertise to inform best practice CM, UM and grievance and appeals workflows.
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This position also requires the provision of legal advice and training to administrative and clinical staff on matters relevant to DMH's mission and operations, such as the Department's regulatory standards, guardianship and commitment law, risk management, and human rights.
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Our guiding goal for our Trust & Safety team is To set the gold standard for supporting inclusive communities, moderator mental health, and socially responsible freedom of speech while keeping pace with platform growth and an evolving regulatory environment.
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