• Medicare /Medicaid Claims Editing…

    Commonwealth Care Alliance (Boston, MA)
    …at this time._** **Position Summary:** Working under the direction of the Sr. Director , TPA Management and Claims Compliance , Healthcare Medical Claims Coding ... reimbursement, public health care programs and reimbursement methodologies (Medicaid and Medicare ) + Medical Coding, Compliance , Payment Integrity and Analytics… more
    Commonwealth Care Alliance (11/25/25)
    - Related Jobs

  • Medicare Outside Sales - Spanish Required

    Fallon Health (Springfield, MA)
    …in our service area, and who have MassHealth Standard, and may have Medicare . It combines MassHealth (Medicaid) and Medicare benefits, including prescription ... to be the leading provider of government-sponsored health insurance programs-including Medicare , Medicaid, and PACE- in the region. **Brief summary of purpose:**… more
    Fallon Health (11/17/25)
    - Related Jobs

  • Director of Quality and Compliance

    Trinity Health (West Springfield, MA)
    …Improvement Plan for the PACE Organization (PO) and ensure overall CMS regulatory compliance . The Director , Quality Improvement and Compliance , in ... including leading quality initiatives and projects. In addition, the Director ensures that data is collected from appropriate sources,... with CMS regulations. Has overall responsibility for the Medicare Part D fraud, waste and abuse Compliance… more
    Trinity Health (12/19/25)
    - Related Jobs

  • OneHome - Medical Director - Part Time

    Humana (Boston, MA)
    …a part of our caring community and help us put health first** The Medical Director relies on fundamentals of CMS Medicare Guidance on following and reviewing ... home health, SNF, DME, dual Medicare /Medicaid and Waiver requests. The Medical Director ...appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. All… more
    Humana (11/27/25)
    - Related Jobs

  • Medical Director - Pharmacy Appeals

    Humana (Boston, MA)
    …health first** The Medical Director relies on broad clinical expertise to review Medicare drug appeals (Part D & B). The Medical director work assignments ... data requires a case by case consideration of the Medicare rules, Humana policies and medical necessity. The Medical... rules, Humana policies and medical necessity. The Medical Director will collaborate with clinicians and support staff to… more
    Humana (12/03/25)
    - Related Jobs

  • Medical Director - Medicaid (remote)

    Humana (Boston, MA)
    …a part of our caring community and help us put health first** The Medical Director relies on medical background and reviews health claims. The Medical Director ... or data requires an in-depth evaluation of variable factors. The Medical Director actively uses their medical background, experience, and judgement to make… more
    Humana (01/01/26)
    - Related Jobs

  • Medical Director - IP Claims Management

    Humana (Boston, MA)
    …of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement to make determinations ... service should be authorized. All work occurs within a context of regulatory compliance , and work is assisted by diverse resources, which may include national… more
    Humana (12/11/25)
    - Related Jobs

  • Medical Director -Payment Integrity

    Humana (Boston, MA)
    …of our caring community and help us put health first** The Medical Director actively uses their medical background, experience, and judgement to make determinations ... at the Inpatient level. All work occurs within a context of regulatory compliance , and work is assisted by diverse resources, which may include national clinical… more
    Humana (12/11/25)
    - Related Jobs

  • Medical Director - Nat'l IP UM Team

    Humana (Boston, MA)
    …of our caring community and help us put health first The Medical Director actively uses their medical background, experience, and judgement to make determinations ... service should be authorized. All work occurs within a context of regulatory compliance , and work is assisted by diverse resources, which may include national… more
    Humana (11/15/25)
    - Related Jobs

  • RN Director , Utilization Management…

    Fallon Health (Worcester, MA)
    …either payer or provider. + Significant experience in regulatory and accreditation compliance requirements for Medicare , Medicaid and the division of insurance ... to be the leading provider of government-sponsored health insurance programs-including Medicare , Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)-… more
    Fallon Health (12/14/25)
    - Related Jobs