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Eligible to be admitted to practice in federal district courts; Ninth Circuit U.S. Court of Appeals; and the U.S. Supreme Court, as required. The incumbent independently handles all phases of litigation, from district court proceedings to Ninth Circuit Court of Appeals.
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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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Demonstrated understanding and knowledge of Medicaid, CMS, SMC/OBC, and MES. Deep Medicaid experience is critical, as well as experience working with the Centers for Medicare and Medicaid Services (CMS) and the new streamlined modular certification (SMC) and outcomes-based certification (OBC.
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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), using skills including but not limited to Hierarchical Condition Category (HCC) Coding, medical coding, clinical terminology and anatomy/physiology, Centers for Medicare and Medicaid Services (CMS) coding guidelines, and Risk Adjustment Data Validation (RADV) Audits.
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The OST is organized and designed to partner closely with programmatic divisions that span the Medicaid and Health Services and Human Services Practices, with the goal of supporting and augmenting existing and new workstreams by providing policy and project management expertise.
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Functions include, conducting in depth investigations making decisions and recommendations on case direction, scope and timing; collaborating with managers and staff in Claims, Provider Network, Appeals and Grievances, Finance, Utilization Management and Analytics throughout the audit lifecycle; ensuring audit compliance with state and federal laws and regulations, contract requirements and company policies and procedures as they pertain to fraud, waste and abuse.
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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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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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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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Follow all Medicare, Medicaid, and HIPAA regulations and requirements. Perform LPN and Home Health Aide supervisory visits, in accordance with state regulations, to evaluate competency and provide appropriate instructions.
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Medicare/Medicaid and/or Health Insurance experience pref. Design, implement, and improve company quality standards in Claims, Provider Enrollment, etc. Conduent is an Equal Opportunity Employer and considers applicants for all positions without regard to race, color, creed, religion, ancestry, national origin, age, gender identity, gender expression, sex/gender, marital status, sexual orientation, physical or mental disability, medical condition, use of a guide dog or service animal, military/veteran status, citizenship status, basis of genetic information, or any other group protected by law.
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Overall acts as an advocate for the Medicaid members to ensure their needs are met. Medical Office Call Center needs 1 year medical insurance or medical office experience. Provides clear and concise information regarding member eligibility status, passport provider change and member benefits.
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Your training will enable you to interview witnesses, research court decisions and Army regulations, process legal claims and appeals, and prepare records of hearings, investigations, courts-martial, and courts of inquiry.
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The HEDIS Data and Reporting Lead reports to the National Medicaid Quality Director and oversees and coordinates all aspects of HEDIS data collection strategy, analytics, and reporting for the Humana Healthy Horizons Medicaid business, and leads the National Medicaid Quality Analytics team.
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