- Humana (Columbus, OH)
- …the PIHPs. + Ensures compliance with accreditation standards, contract, and Center for Medicare and Medicaid Services ( CMS ) requirements. + Works closely with ... to Performance/Quality Improvement Coordinator, Behavioral Health Network Director, Quality Management Coordinator, and Behavioral Health Quality Management … more
- Molina Healthcare (Cincinnati, OH)
- …oversight of processes that track, evaluate, and submit encounter deletions for Medicare Advantage, ACA, and Medicaid lines of business. This role has ... received from providers, improve completeness of encounter data with states, CMS , HHS to reconcile data. + Responsible for encounter submissions, rejection… more
- Humana (Columbus, OH)
- …or CMS guidelines, assessment and documentation practice + Case Management certification (CCM) + Bilingual in English and Spanish **Work-At-Home Requirements** ... Our nurses are titled Care Managers, because our case management services are centered on the person rather than...of the business day, primarily through an auto dialer system . Environment is fast paced and requires ability to… more
- Highmark Health (Columbus, OH)
- …leadership, problem-solving, data analytics, team development, communication, implementation, and project management . The incumbent often plays a central role in the ... include elements of team leadership, problem-solving, data analysis, project management , communication, implementation, and provider and/or provider-facing team education… more
- Humana (Columbus, OH)
- …data driven methods to develop and influence formulary strategies for Humana's Medicare line of business. + Utilizes broad understanding of pharmacy, managed care, ... pharmacy related field + Experience in Formulary strategy/development and CMS Part D guidance + Experience in analysis and...with staff in different positions and all levels of management positions. + Ability to prioritize, organizes, and executes… more
- Molina Healthcare (Akron, OH)
- …Action Items (SAIs) including assisting and executing projects and tasks to ensure CMS and State regulatory requirements are met for pre-pay edits, post payment ... and experience. + At least 3 years of Experience with Medicaid and/or Medicare . + Proven experience owning operational projects from concept to execution, especially… more
- CenterWell (Columbus, OH)
- …procedures + Compact License preferred + Previous experience in utilization management within Insurance industry + Previous Medicare Advantage/ Medicare ... in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review criteria and who is interested in being part… more
- Molina Healthcare (OH)
- …and demonstrate proficiency in running all applicable risk models including the various CMS models for Medicare Advantage members, the HHS model for Commercial ... Performs analysis across multiple states and lines of business ( Medicare , Medicaid, Marketplace ACA). **KNOWLEDGE/SKILLS/ABILITIES** + Compiling and organizing… more
- Molina Healthcare (Akron, OH)
- …contracted provider network. They are responsible for network management including provider education, communication, satisfaction, issue intake, access/availability ... staff to determine; for example, non-compliance with Molina policies/procedures or CMS guidelines/regulations, or to assess the non-clinical quality of customer… more
- CenterWell (Mount Vernon, OH)
- …review and outcomes of care analysis to determine efficiency, the efficacy of case management system as well as any other systems and process. Competently ... final audits/billing are completed timely and in compliance with Medicare regulations. + Coordinates communication between team members/attending physicians/caregivers… more