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Role Overview : This role, Program Integrity Audit Manager, oversees and manages the coordination of program integrity activities across the Medicaid enterprise and oversees the Program Integrity (PI) staff and contractors who are responsible for auditing fee-for-service and Managed Care Entity (MCE) Medicaid providers.
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About NYC Health + Hospitals MetroPlus Health provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc.
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Experience in health care, health plans, Covered California, Medicaid Managed Care Plans (MCPs), Medicare Advantage, Medicare Part D, Special Needs Plans (SNPs), and/or Medicare-Medicaid Plans (MMPs)/Cal MediConnect.
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Managed care, value-baed payment model, quality and population health management experience. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus Health's network includes over 27,000 primary care providers, specialists and participating clinics.
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Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
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The ideal candidate will have extensive business leadership experience, with several years in a managed care environment leading a network development/provider relations function, including proven experience leading contracting for Medicare products.
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Experience working with Medi-Cal Managed Care Plans (MCPs) Medicare, and health services experience preferred. Working knowledge of managed care. Coach and train staff to identify the potential quality of care/service and accessibility concerns and refer to Grievance and Appeals (G&A), Case and Disease Management (CM/DM), Behavioral Health/ABA or Quality Improvement (QI.
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Knowledge of health care, managed care, Medicare or Medicaid. Regions 1-4 include all counties from Ballard, Carlisle, and Hickman to Henry, Shelby, Marion, Casey, Pulaski, and McCreary counties.
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This key leader position provides strategic leadership, value-based guidance, sets operational direction and performance expectations for both leaders and associates in Humana's sales operational areas including Medicare Advantage, Prescription Drug Plans, Medicare Supplement, Medicaid Managed Care Plans and Individual Major Medical insurance plans.
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Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and/or Commercial products, or other Medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management.
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Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an inpatient environment and/or related to care of a Medicare type population (disabled or >65 years of age.
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Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work. The Medical Director conducts Utilization Management of the care received by members in an assigned market, member population, or condition type.
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Are in compliance with regulatory agencies, including but not limited to, Covered California, the Centers for Medicare and Medicaid Services (CMS), the California Department of Health Care Services (DHCS), and the California Department of Managed Health Care (DMHC), in addition to collaboration with, inter-departments to ensure member needs are met while simultaneously building strong peer relationships.
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Provides Medicare, Medicaid (case mix), and managed care oversight to ensure appropriate clinical services are provided and appropriate reimbursement is received for each resident.
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Two (2) years of experience with managed care or other relevant industry experience. Knowledge of Principles and practices of managed care. Knowledge of and experience with state and Federal regulatory and other requirements and practices related to Covered California, Medicare and Medi-Cal (Medicaid), Title 19 (USC)/Title 29 (USC and CCR), Title 22 (CCR), Title 28 (CCR), Title 42 (USC and CFR), CA Welfare and Institutions Code, and CA Health and Safety Code.
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