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The RN / MDS COORDINATOR manages the overall process and tracking of all Medicare/Medicaid case-mix documents to ensure appropriate reimbursement for all services provided within the nursing.
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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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Prior job title or occupational experience: Hospital reimbursement required, including Medicare and Medicaid cost report experience. the Medicare cost report Medicaid DSH eligibility.
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Work Experience (Years and Area): 10 years in healthcare, with at least 5 years¿ experience in STAR+PLUS, managed care, case management, or Medicaid waiver services. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
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The RN Care Manager is responsible for care management and care coordination services of both Medicare and Medicaid benefits for members enrolled through Florida Complete Care (FC2) Medicare Institutional Special Needs Plan (ISNP) and Institutional Equivalent Special Needs Plan (IESNP) and the Statewide Medicaid Managed Care Program if applicable.
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Experience or understanding of Medicare and Medicaid claims, ICD10 codes, HCPCS, Diagnosis Related Groups (DRG). Manipulates and extracts Medicare, Medicaid, and other healthcare claims data stored in Cloud environment using appropriate software such as SAS, Snowflake, Python, R, SQL, and other software as appropriate for the task.
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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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Build models and conduct analytics that contribute to Medicare and Medicaid fraud, waste and abuse efforts. Continuously learns Medicare and Medicaid policy and policy changes.
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The counselor will maintain the plan, updating the PCP based on the needs of the client and/or requirement of the Medicaid/ Medicare service definition and LME/MCO. The counselor is responsible for the upload of all Medicaid/ Medicare related documents to the appropriate LME/MCO provider portal.
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Relevant experience in a health-related, scientific, or public policy/business discipline with extensive quantitative methods/statistical knowledge. Minimum 4-year degree in statistics, mathematics, computer science or related field or possesses a minimum of 6 years of data analysis experience within the healthcare industry.
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Works closely with the Governance, Risk & Compliance (GRC) teams (Medicare, Medicaid, Privacy, Fraud, Waste & Abuse) for dissemination of new or revised requirements applicable to the delegated third-party.
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The Director, MA & Medicaid Contracting on the Strategic Payer Partnerships team will execute Aledade’s Medicare Advantage and Medicaid value-based care contracts with national and regional health plans as we help primary care providers shift into value-based care.
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Knowledge of Medicare Risk Adjustment and Medicaid. Knowledge of Medicare Risk Adjustment and Medicaid. The Vice President ensures the program complies with all Centers for Medicare and Medicaid Services (CMS) guidelines, NYS laws (Article 28, 36, and 44), and all other licensure requirements and standards of performance.
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Conducts case management program activities in accordance with departmental, corporate, NYS Department of Health (DOH), Centers for Medicaid & Medicare Services (CMS), Federal Employee Program (FEP) and National Committee for Quality Assurance (NCQA) accreditation standards, as appropriate to the member’s case assignment.
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Be responsible for the performance management and strategy development for Medicaid and Medicare risk adjustment at the company, partnering closely with CDI, Medical Records, Billing, and other Activation Team leaders.
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medicare medicaid rn or jobs Company: Unitedhealth Group
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