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If employed at one of our senior living communities that receives Medicare or Medicaid funding, team members must not be considered an "Excluded Party" as defined by the U.S. Department of Health and Human Services, any state Medicaid Programs, and any additional federal and state government contract programs.
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This position is responsible for ensuring the quality of care by monitoring, assessing, and maintaining records regarding the MDS and Care planning process in compliance with the requirements of Medicare and Medicaid and ensuring compliance with PDPM, Medicare Advantage plans, and Medicaid Managed care.
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Knowledge of CMS claims data, including Medicare, Medicaid, and Marketplace, in the IDR or CCW environment with Fee-for-Service (FFS), Medicare Advantage encounter data, Medicaid data in the Transformed Medicaid Statistical Information System (T-MSIS), or Prescription Drug Event (PDE) data.
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Familiar with Medicare and/or MassHealth (Medicaid) insurance products, programs, or operations. + Experience with MassHealth or Medicare programming and insurance products (i.e., ACO, MCO, PACE, SCO, or OneCare.
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Long term care (skilled nursing facility) Medicare , Medicaid, and Managed Care billing experience is highly preferred. This includes all Medicare, Medicaid, Managed Care and Insurance payments.
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Perform DME billing for Medicare, Medicaid, Tricare, and other private insurances. Required - High School diploma or equivalent plus 2 years' experience in Medicare/Medicaid and commercial billing - preferably in Durable Medical Equipment setting.
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This job will deliver value to the Health Plan, and its beneficiaries enrolled in Risk Adjusted government programs such as Medicare Advantage (MA) and Affordable Care Act (ACA), using skills including but not limited to Hierarchical Condition Category (HCC) Coding, medical coding, clinical terminology and anatomy/physiology, Centers for Medicare and Medicaid Services (CMS) coding guidelines, and Risk Adjustment Data Validation (RADV) Audits.
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The programs the AVP will have oversight for include but are not limited to: MACRA/MIPS, 21st Century CURES, Centers for Medicare and Medicaid Innovation (CMMI) projects; Accountable Care Organizations (ACO); Advanced Alternative Payment Models (AAPM); Medicare Advantage; and commercial payer value programs.
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Collaborate with FWA Subject Matter Experts and Machine Learning Developers to deploy and evaluate FWA models and algorithms that detect and describe actionable FWA leads for the HFPP. The Machine Learning Manager directs the ML Ops team in using tools such as Python to analyze healthcare claims across Medicare, Medicaid and private payers within a multi-billion record database made up of a large partnership of public and private healthcare payers.
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Significant exposure to ACHC, Medicare and Medicaid reimbursement and regulations, Stark Law, Anti-Kick Back Laws and fraud and abuse laws. Significant exposure to ACHC, Medicare and Medicaid reimbursement and regulations, Stark Law, Anti-Kick Back Laws and Fraud and Abuse Laws.
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The primary focus of your regulatory work would be the Department of Health and Human Services (HHS) and specifically, the Centers for Medicare and Medicaid Services (CMS), Center for Medicare & Medicaid Innovation (CMMI), and Food and Drug Administration (FDA.
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Ensures that all donor evaluations and organ cases are carried out based on SHSC, Centers of Medicare and Medicaid Services (CMS), OPTN / UNOS, Association of Organ Procurement Organizations (AOPO) and Centers for Disease Control (CDC) guidelines and recommendations.
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Perform denials, incorrect payments/underpayments, past due receivables, and complete follow-up processing of Medicare and other participating commercial insurances in a timely manner. Responsible for all billing and collection functions for Ballad Health Medical Equipment Services/Mediserve to include charge entry, payments, and A/R management.
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Our health plan serves more than 640,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans. PALS: Children Services, Cardiovascular Lab, Emergency Department, GI Lab, Interventional Radiology, Surgical Services Pre-Op and Recovery Room.
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Preferred QualificationsBilingual (English/Spanish) or (English/Burmese)Prior nursing home diversion or long-term care case management experiencePrior experience with Medicare & Medicaid recipientsExperience working with a geriatric populationExperience with health promotion, coaching and wellnessKnowledge of community health and social service agencies and additional community resourcesAbout HumanaYour growth is what drives Humana forward.
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