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Job Summary: Under general direction of the Case Management Director, the RN Case Manager utilizes well-developed knowledge and skills in areas of utilization management, medical necessity, patient status determination, Medicare compliance, and revenue cycle; collaborates with the multidisciplinary patient care team for optimal patient care outcomes, discharge planning, and readmission prevention; and participates in ongoing assessment of systems and clinical care processes.
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Comfort treating adolescents (13-17), adults, and Medicare clients (preferred) Individual professional malpractice liability insurance policy Submission of a fully completed, signed CAQH application Individual NPI number Current residence in the USA Note: Talkspace therapists/counselors work remotely and only with clients in the state(s) where they are licensed and allowed to practice.
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Monitor KPIs through analytics and identify providers for Medicare Risk Adjustment training, programs and documentation/coding resources. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
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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/or Affordable Care Act (ACA) using skills including but not limited to Hierarchical Condition Category (HCC) Coding, medical coding, clinical terminology and anatomy/physiology, and Centers for Medicare and Medicaid Services (CMS) coding guidelines.
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Ensure a consistent customer experience across our Company’s division and functional areas and share key learnings to support customer needs by effectively communicating and collaborating with the in-scope customer team: Customer Team Leader, Key Account Manager, Nurse Educator, Field Reimbursement Associate, Medicare Account Executive, and more.
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In coordination with Outreach and Enrollment, Direct Health Benefits functions to screen self-pay patients for alternate resources and apply for Medicaid, Medicare, VA, HRSA, TSHIP, grants, and ACA.
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Knowledge of Medicaid/Medicare regulations/standards, as well as cost reporting, profit and loss, and budget compliance. Bachelors degree in Healthcare Administration, Business Administration/Management, Finance, a clinical specialty or equivalent with preference of a Masters degree in one of these fields.
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5+ years of healthcare actuarial experience; Experience working with Medicare Advantage pricing and bid development. Experience certifying the Medicare Advantage Bid. Provide expertise and consultation to support the Medicare bid process and pricing strategy.
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Principles of managed care (i.e., Medicare, Medicaid, Blue Cross, Campus, and related federal and state regulations and requirements. Provides subject matter expertise and guidance for Patient Access in rural locations in the areas of Medical, Behavioral Health, Optometry, Dental, and Audiology Ancillary services through dotted line reporting.
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Providing sound, practical judgment in the interpretation and application of relevant laws and regulations, including the Anti-Kickback Statute, the Beneficiary Inducement Statute, Medicare/Medicaid, False Claims Act, Stark Law, HIPAA and state health information privacy laws, and marketing and advertising laws applicable to the marketing and promotion of medical products.
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As a member of the Quality Measures mPages regulatory reporting team, you will use basic knowledge of software architecture to perform tasks associated with developing, debugging or designing software applications and dashboards that run in our clients’ EHR (Electronic Health Record) system to enable our clients’ to track compliance with the requirements of the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC.
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Follows Medicare guidelines regarding patient choice, admit/discharge notifications, and appeals. Follows Medicare guidelines regarding utilization review. Facilitates arrangement of post-acute care services.
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The ideal candidate will also be knowledgeable in Medicare, Medicaid, and private insurance, as well as the ability to complete relevant insurance documentations. The ideal candidate will also be knowledgeable in Medicare, Medicaid, and private insurance, as well as the ability to complete relevant insurance documentations.
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Must meet Center for Medicaid/Medicare Services (CMS)-approved national certification requirements within the CMS timeline. Minimum of 3 months of dialysis, phlebotomy, or CNA/PCA experience preferred.
Full-timeExpandApply NowActive JobUpdated 7 days ago - UpvoteDownvoteShare Job
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Extensive experience in healthcare contracting, with a critical understanding of PBMs, National Health Plans, Medicare Part D/B, GPOs, VA/DoD, Medicaid, and the evolving market landscape. Minimum of 12 years of pharmaceutical industry experience, with significant expertise in at least two of the following areas: Channel Strategy, Finance, Pharmacy, Pricing, Trade, or Market Access.
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medicare job in Juneau, AK
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