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Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope. May also engage in grievance and appeals reviews.
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Strong knowledge in community LTSS programs, including HCBS waivers such as 1915(c), 1915(i), 1915(j), and 1915(k), along with Medicaid State Plan benefits, PACE, SNFs, and ICF-IID. Knowledge must include federal laws and regulations governing the programs.
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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) through Hierarchical Condition Category (HCC) coding, medical coding, clinical terminology and anatomy/physiology, Centers for Medicare and Medicaid Services (CMS) coding guidelines, and support of Risk Adjustment Data Validation (RADV) audits.
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Familiarity with Department of Defense (DoD), Federal, State, non-profit healthcare systems and organizations, to include DoD Tri-Service Military Healthcare Systems, TRICARE purchased care system, Medicare, Medicaid and the Veterans Administration (VA) Preferred.
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Position Description The Alabama Medicaid Agency (AMA) is preparing for a major transition from a monolithic Medicaid Management Information System (MMIS) with 14 different business functions operated by a single vendor to an interoperable, modular system based on a Service Oriented Architecture (SOA) operated by multiple vendors.
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Ensure program meets all standards, to include DMH, Medicaid, Life Safety, and any other applicable standards. The Crisis Center is a 24/7 facility that triages individuals experiencing a behavioral health crisis, as an alternative to an emergency room or unnecessary arrest.
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This position reports to the Senior Director, Market Access and is responsible for establishing and leveraging credible relationships within all assigned accounts in Mid Atlantic (MD, VA, DE, DC) which will include the following account types; regional payers, regional specialty pharmacies, regional PBMs, select IDNs and state Medicaid agencies to achieve and maintain open and appropriate access for all Sanofi Specialty’s specialty products.
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Experience with State Government, Medicaid, CHIP, and DHR business area or health care industry. Knowledge of IIS Administration Multiple JavaScript Frameworks SoftwareAG webMethods InRules SSRS MS Team Foundation Server.
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5 years of experience in MMIS or domain knowledge of Medicare, Medicaid or with a major health care payer. 5+ years of experience in MMIS or domain knowledge of Medicare, Medicaid or with a major health care payer.
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Knowledge of UM standards, NCQA requirements, CMS guidelines, Milliman guidelines, and Medicaid/Medicare contracts and benefit systems. Knowledge of UM standards, NCQA requirements, CMS guidelines, Milliman guidelines, and Medicaid/Medicare contracts and benefit systems.
ExpandApply 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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Liaison to Services team coordinating efficient and accurate member ad provider servicing as well as Grievance and Appeals processing according to CMS requirements and regulations. Liaison to Services team coordinating efficient and accurate member ad provider servicing as well as Grievance and Appeals processing according to CMS requirements and regulations.
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A leading Information Technology provider for Federal, State & Local government agencies. A certified minority-owned small business government contractor with capabilities related to Public Health IT, Criminal Justice, Transportation, and Defense.
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To support this effort, the AMA is seeking for a talented, motivated and experienced Project Analyst to be a member of the Medicaid Enterprise Systems (MES) team. The Alabama Medicaid Agency (AMA) is preparing for a major transition from a monolithic system with 14 different business functions to an interoperable, modular system based on a Service Oriented Architecture (SOA.
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Knowledge of legislative/oversight bodies (e.g., URAC-Utilization Review Accreditation Commission, CMS-Centers for Medicare & Medicaid Services, NCQNational Committee for Quality Assurance, and ERISEmployee Retirement Income Security Act of 1974.
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