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May also engage in grievance and appeals reviews. Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and/or Commercial products, or other Medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management.
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Works effectively with DHS, Income Maintenance (IM) and ICs to ensure all participants maintain financial eligibility for Medicaid and the IRIS program. Works effectively with DHS, Income Maintenance (IM) and ICs to ensure all participants maintain financial eligibility for Medicaid and the IRIS program.
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Acts as an advisor and consultant in the establishment of operational policies of the practice to include: (1) Purchasing and capital allocations; (2) Managed care plan participation; (3) Budget and practice expenses; (4) Medicare/Medicaid participation; (5) Billing and collection of professional fees; (6) Personnel management and related policies; (7) Risk management and quality assurance; and (8) Coding compliance.
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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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Review Level of Care for iCare members including follow-up consultation with Grievance and Appeals or Enrollment/Eligibility/Fiscal staff. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
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This position interfaces with the Department of Health Services (DHS), the Division of Hearings and Appeals (DHA), Ombudsman Program, the. Maintains knowledge of grievance/appeal reporting requirements for the Office of the Center of Medicare/Medicaid Services, DHS, and Metastar.
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This developer will work on Medicaid claims related data like: Finance, Claims, Encounter, and Capitation Fees to put together a single source of truth for the Data Warehouse that can be used by various teams for data extracts, reporting, and advanced analytical data mining purposes.
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The OIG reports directly to the Department of Health Services (DHS) Secretary and is charged with protecting the taxpayers of Wisconsin by preventing and detecting fraud, abuse, and waste of public assistance programs such as Medicaid, FoodShare, WIC, and FamilyCare.
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Knowledge of reimbursement principles including pharmacy and medical benefit/buy & bill benefit design, coding, billing, prior authorization, and appeals processes. All responsibilities of the Associate Director will be carried out with strict adherence to the JJIM Credo and HCC Guidelines, in line with the FRM Rules of Engagement.
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1+ year of experience working with government-sponsored programs, particularly long-term care Medicaid. The Community Partnership Specialist collaborates with local TMG leadership and other teams to effectively develop and implement area outreach plans.
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Prior involvement with Wisconsin state systems and/or familiarity with managed care systems and waiver services, including Developmental Disabilities (DD), Brain Injury (BI), Medicaid Waiver. Bachelor's degree in: Human Services, Psychology, Counseling, Allied Health, Health and Human Services, Human Services Management, Social Work, or Behavioral Science or a related field.
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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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Partner with Operations and Principal and Major Gifts leadership and the VP of Development in the creation and implementation of annual themes and branding work including newsletters, annual and year appeals, and other outward facing materials.
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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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