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The RN Utilization Review Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services CMS Inpatient List.
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The position also requires Qualified Mental Health Associate (QMHA), as the position is located in the Multnomah County Community Health Center, which is a covered Federally Qualified Health Center (FQHC) under the Bureau of Primary Health Care and the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services.
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Minimum three years progressive professional experience in health care, including a minimum of two years in a grievance and appeals or related area such as medical or utilization management required.
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Strong knowledge of and/or experience with government programs regulatory, operational, financial, and clinical requirements for the delivery of health insurance and managed care products and services, including Medicare, Medicaid, MMP, LTSS, SNP, Duals, CHIP and behavioral health, as well as the associated and relevant federal, state and local regulatory entities.
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Participates in the development and implementation of the behavioral health sections of the Quality Management (QM)/Utilization Management (UM) Plan. Oversees the administration of all BH QM/UM and performance improvement activities, encompassing grievances and appeals, and contributes to various other subcommittees such as Compliance and Pharmacy.
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Note: The Centers for Medicare & Medicaid Services (CMS), in collaboration with the Centers for Disease Control and Prevention (CDC), require COVID-19 vaccinations for all Medicare and Medicaid certified providers.
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Utilization Review Specialist BenefitsKnowledge and skills at a level normally acquired through the completion of a Bachelor's Degree in human service or behavioral health with two (2) years experience in the field of chemical dependency, or adolescent treatment or equivalent experience and training in behavioral health field.
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The RN Utilization Review Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS. CHRISTUS Santa Rosa Hospital - Westover Hills (CSRH-WH) is a 150-bed hospital serving the fastest growing area of San Antonio.
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Job Description & Requirements Specialty: Case Management Discipline: RN Start Date: ASAP Duration: Ongoing Employment Type: Staff Agency: The Christ Hospital Home Health Care Our culture and people are what set us apart from other post-acute care providers.
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We CARE for our patients like they are our own FAMILY. Note: The Centers for Medicare & Medicaid Services (CMS), in collaboration with the Centers for Disease Control and Prevention (CDC), require COVID-19 vaccinations for all Medicare and Medicaid certified providers.
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About the roleThe Senior Specialist, Risk Adjustment for Medicare Advantage (MA) and Affordable Care Act (ACA) lines of business will work with management to meet communicated single and departmental goals, deadlines set forth by Centers for Medicare & Medicaid Services (CMS) and Health and Human Services (HHS) , and be active and engaged in establishing Risk Adjustment processes.
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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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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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Represent and serve as point person for the state health plan and Centene Corporation to outside trade groups/stakeholders including state AHIP organization, state medical association, state hospital association and related Medicare and Medicaid business vendors.
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Health care product experience including one of the following health care programs: Medicaid/Medi-Cal, Covered California, or Medicare Special Needs Plan. Experience working cross-functionally with Care Management, Social Services, Health Education, and other social service or clinical teams.
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