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Coordinates and performs medical record reviews prior to and following annual wellness visits and other identified visits to determine maximizing revenue thru appropriate coding and billing and compliance with Medicare Risk Adjustment metrics.
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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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Is prepared to conduct PPS meetings maintaining MDS assessments per Medicare schedule and maintain PPS board for monitoring of Medicare days and RUGs utilization in the absence of the Care Management Coordinator.
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Willing to learn and utilize various IT platforms, including, but not limited to, EMR systems, care management software, Looker, Tableau, and project management software. , when appropriate, for a variety of clinical care and care management services.
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The Compliance Director is responsible for oversight of all departmental compliance as it pertains to the HRSA scope of project for HCC, FTCA, policy management and special projects related to high-risk areas.
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Minimum of six (6) years in a managed care operations, working with one or more of the following areas: Utilization Management, Claims, Pharmacy Operations, Compliance, FDR oversight activities, Quality Management, Care Management, and/or Grievances and Appeals.
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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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They collaborate with internal departments including Finance, Compliance, Marketing, IT, Configuration, Provider Network Management, Member and Provider Enrollment, Enterprise Project Management, Claims, and Customer Service.
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Working knowledge of compliance issues applicable to Accountable Care Organizations, Clinically Integrated Networks, Medicare Shared Savings Programs, value-based healthcare initiatives.
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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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This position serves as an internal consultant to management and staff regarding compliance with Federal and State laws and regulations (Centers for Medicare and Medicaid, Nevada Division of Insurance, Texas Department of Insurance, Florida Office of Insurance Regulation, and the Florida Agency for Health Care Administration) contract provisions, accreditation standards, and internal policies and procedures.
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Works closely with theDirector of Value Based Careand/or the Lead RN Care Manager to provide CCM services primarily to a medium acuity panel of Traditional Medicare and Medicare Advantage plan patients who are assigned to his/her care.
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Sage Health builds enriching neighborhood health centers that are easy to access, provide or arrange for all of our patients' healthcare needs, and partner with Medicare Advantage plans that fully cover primary care.
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The Senior Risk Management Analyst is responsible for supporting, facilitating, and training associates on third-party risk programs designed to ensure the identification and mitigation of risks; management of controls and safeguards to minimize the impact of potential and existing third-party risks affecting the organization; compliance with laws, regulations, standards, policies/procedures, and organization frameworks; and monitoring and effectuation of remediation of issues identified.
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JOB SUMMARY : Under direction of the Nurse Manager of Clinical Services, the RN Care Manager is responsible for triaging, coordination, documentation, communication, and tracking of patient calls, cases and records for a panel of high acuity Traditional Medicare and Medicare Advantage Plan patients in the Chronic Care Management (CCM) Program.
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medicare compliance care management jobs Title: compliance specialist Company: Metroplus Health Plan
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