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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) 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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A minimum of 2 years experience in hospital billing/pre-authorization or insurance verification with demonstrated knowledge of health insurance plans including: Medicare, Medicaid, HMO's and PPO's required.
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The ideal candidate would also possess prior experience working in a variety of MA units beyond growth and acquisition (member retention, customer care, care coordination, appeals and grievances, etc.
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Legal research and drafting of client correspondence, discovery devices, summations, appeals and appellate briefs. Leading law firm is seeking a Workers Compensation Attorney with 2-7 years of experience.
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The Risk Adjustment (RA) Analyst assists in the accurate and comprehensive data submission to regulatory entities such as the Centers for Medicare & Medicaid Services (CMS) for all risk adjustable populations.
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Contract Services negotiates with more than 100 private contractors and administers the Public Defense Services Account which funds representation and related services for more than 350,000 cases during the biennium for criminal, juvenile, and civil commitment cases at the trial level and in those appeals not assigned to the Appellate Division.
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Duties And ResponsibilitiesClaims Processing & Quality Assurance Adjudicate all claims types including Dental, Vision and Medical claims for inpatient and outpatient facilities, physician claims, In and Out of Network claims, Medicaid reclamation (HIPD),outpatient lab and radiology, accident and Third-Party Liability (TPL) claims, by calculating benefit due to approve or deny, based on SPD and within accepted corporate cycle timeframe.
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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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Completes daily formulary operational processes, including tracking, processing, and obtaining appropriate documentation for pharmacy medical exception requests, prior authorization requests, reconsiderations, and appeals.
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Revenue agents, counsel attorneys, appeals officers, and/or specialists throughout IRS to leverage and expand. the team in conferences with appeals, including issue resolution meetings such as fast track.
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4+ years of State government experience in Medicaid, MMIS, eligibility/enrollment systems, claims process or related experience. Expertise in some/all the following: Medicaid - MMIS - Health care.
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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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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 Salem, OR
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