- Humana (Kenosha, WI)
- …ongoing health issues, assess the member's response to interventions, or when a medical complaint or event affecting the member's health occurs. + Perform routine ... In crisis situations, provides appropriate assessment of psychiatric, behavioral or medical problems and implements interventions in conjunction with other staff to… more
- CVS Health (Madison, WI)
- …and prosecution of health care fraud to recover lost funds. Responsible for compliance with state and federal regulations mandating the reporting of corporate ... experience in a Healthcare Program Integrity, Medicaid Special Investigation or Medicaid / Medicare / Commercial Compliance role + Strong verbal and written… more
- Highmark Health (Madison, WI)
- …related internal, concurrent, prospective and retrospective coding audit activities. Reviews medical records to determine data quality and accuracy of coding, ... with coding principles and guidelines. Promotes cooperation with CDMP and compliance programs to improve documentation which supports compliant coding. Interacts… more
- Humana (Madison, WI)
- …oversight of up to 700 BPO partner associates across two vendors supporting all Medical lines of business ( Medicare and Medicaid) + Focuses on improvement ... for continuous improvement in initial claims processing for all medical lines of business. The role will focus on...to a better quality of life for people with Medicare , Medicaid, families, individuals, military service personnel, and communities… more
- Humana (Madison, WI)
- …have met all company training requirements for company, quality, and regulatory compliance . + Analyzes course evaluations to judge the effectiveness of training ... successfully working as a Care Manager/Care Coach/Care Coordinator/Service Coordinator in a Medicare or Medicaid market **OR** two (2) or more years of professional… more
- Molina Healthcare (WI)
- …and monitoring Molina Health Plan's pharmacy benefit programs in accordance with all federal and state laws. Jobs in this family include those involved in formulary ... therapeutic drug monitoring, drug regimen review, patient education, and medical staff interaction), and oversight (establishing and measuring performance metrics… more
- Evolent (Madison, WI)
- …Computer Proficiency + Not under current exclusion or sanction by any state or federal health care program, including Medicare or Medicaid, and is not identified ... make denial determinations as a specific case warrants. + Converses with medical office staff in order to obtain additional pertinent clinical history/information;… more
- Humana (Madison, WI)
- …Coding Educator is responsible for reviewing and analyzing internal data and medical records, as well as coordinating educational sessions with providers to enhance ... guidelines + Prior experience in provider education + Strong knowledge of medical record review + Understanding of billing, claims submission, and related processes… more
- CenterWell (Madison, WI)
- …collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review criteria ... Previous experience in utilization management within Insurance industry + Previous Medicare Advantage/ Medicare /Medicaid Experience a plus + Current nursing… more
- Marshfield Clinic (Marshfield, WI)
- …Discharge Data Set (UHDDS) and assignment of the appropriate MS-DRG ( Medicare Severity-Diagnosis Related Group) or APR-DRG (All Patients Refined Diagnosis Related ... multi-specialty inpatient services. This individual understands and applies applicable medical terminology, anatomy and physiology, surgical technology, pharmacology and… more