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Possesses at least 6+ years recent experience with Medicare and/or Medicaid Part A, B, & DME claims, coding, and reimbursement procedures, service and coverage policies, coordination of benefits, as well as provider and beneficiary eligibility.
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At Healthcare in Action, we serve patients experiencing homelessness through an innovative "street medicine" approach by contracting with Medicare and Medicaid health plans as well as hospitals and health systems.
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Minimum Experience: Three (3) years contract negotiations in a managed care environment working with Medicare and Medicaid fee schedules required. Knowledgeable of Commercial, Medicare, Medicaid lines of business required.
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An in-depth understanding of managed care, Medicare and Medicaid regulations, Model of Care and NCQA Population Health requirements are necessary. An in-depth understanding of managed care, Medicare and Medicaid regulations, Model of Care and NCQA Population Health requirements are necessary.
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Exhibiting familiarity with healthcare compliance regulatory agencies and a general understanding of healthcare laws and regulations (e.g., HIPAA, CMS, Medicare, Medicaid, Affordable Care Act, Anti-Kickback, Fraud and Abuse laws, False Claims Act, Accreditation, Research and Academic Medical Center experiences); and.
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Under the direction of the PFS Manager, the Senior Government Billing and Collections Representative is responsible for a variety of payer yield activities related to accounts reimbursed by a government payer, including Medicare, Medicaid, TRICARE, and Veterans Administration, among others.
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Sending correspondence to Members or CMS (Center for Medicare and Medicaid Services) to gather information or provide updates for corrections. Researching validating and reconciling enrollments from the error reports and CMS (Center for Medicare and Medicaid Services) daily files.
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Obtain managed care and Medi Cal or Medicaid authorizations including bedholds. Track Medi Cal and Medicaid redeterminations. Assist with Medi Cal or Medicaid applications. Certificates, Licenses, Registrations Knowledge and experience with PCC preferred.
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Experience working on government, Recovery Audit Contractor (RAC), Medicare Administrative Contractor (MAC), Targeted Provider Education (TPE), Comprehensive Error Rate Testing (CERT), Office of Inspector General (OIG), and other Medicaid, Medi-Cal and other regulatory audits.
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6 months of Medi-Cal/Medicaid or health services experience. Addresses member and provider inquiries, questions and concerns in all areas including eligibility, enrollment, claims or authorization status, benefit interpretation and referrals/authorizations for medical care in-person or telephonically.
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At least 2 years of experience applying knowledge of Medicare, Medicaid, and Managed Care reimbursement guidelines. Our company is continuing to grow and we're looking to add a Prior Authorization Specialist to support our patient care operations department.
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Knowledge of CMS (Centers for Medicare and Medicaid Services) coverage and criteria. Work experience applying evidence-based criteria (i.e.: MCG, lnterqual); Health plan medical policy / clinical coverage guidelines.
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Ensures all clinical operations comply with Medicare and Medicaid guidelines and other managed care policies. We are one of only two certified Pediatric ICUs in Orange County and the only hospital in Fountain Valley and Huntington Beach with a Level III Neonatal ICU. We’re proud of the efforts of our physicians, nurse and staff who strive to provide you with the best care possible.
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Current California LVN/LPN. On-site, telephonic or faxed clinical reviews (admission and concurrent) for MCMF patients in identified settings. Support after hours duties for inpatient workflow if assigned.
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Thorough understanding of Medicaid Waiver systems and community resources. Thorough understanding of Medicaid Waiver systems and community resources. Knowledge of or willingness to learn about the various aspects of Care Coordination, QA/QI, PCMH and any related programmatic or regulatory needs.
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medicaid job Company: Association For Community Affiliated Plans in Orange, CA
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