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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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Prepare code and queries using the Medicaid Administrative Reporting System (MARS) data warehouse or other systems developed or used to track Medicaid data. Two years of professional experience with Medicaid program support or system development.
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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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Minimum two years of professional experience working with Medicaid appeals process. + Minimum two years of professional experience in determining Long Term Care and Waiver Medicaid eligibility.
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Professional experience in a healthcare field, Medicaid eligibility, or Medicaid program support. Assists with the activities of one or more Medicaid Technology Development (MTD) project teams as assigned.
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The purpose of the Sr. Patient Registration Specialist is to conduct the eligibility verification screening, documentation collection, and financial assessments for all clinic patients accessing services, including verifying eligibility for HIP and Ryan White funded programs, Patient Protection and Affordable Care Act insurances, and Medicaid or Medicare.
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Administers the day-to-day operational functions of the Medicaid fee for service programs. Supervises the auditing of eligibility enrollment of all Medicaid programs statewide. Analyzes multi-mullion dollar Medicaid claim data and project the fiscal impact for budget forecasting.
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Working knowledge of and experience in Office of Aging and Adult Services (OAAS), Bureau of Health Services Financing (BHSF), Department of Health and Hospitals (DHH), Medicaid, Office of Citizens with Developmental Disabilities (OCDD), and/or Home and community-based waiver services.
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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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Collaborates and coordinates with other experts, revenue agents, counsel attorneys, appeals officers, and/or specialists throughout IRS to leverage and expand expertise and ensure consistent application and interpretation of tax laws within those areas.
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Assist with IRS examinations and appeals, including responses to Information Document Requests, Notices of Proposed Adjustments and preparation of appeals protests. Our clients are enterprises as diverse as sophisticated financial institutions and start-ups, global public firms, and middle-market companies, as well as high net worth individuals, family offices, not-for-profit organizations, and entrepreneurial ventures across a variety of industries.
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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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Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system. Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system.
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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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appeals medicaid jobs in Baton Rouge, LA
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