- Molina Healthcare (Racine, WI)
- …**Job Summary** Responsible for being the SME (Subject Matter Expert) for Medicaid risk adjustment programs in multiple states. Maintain risk adjustment model, ... available to lead national risk adjustment studies. Prior experience in Medicaid risk adjustment is not required. **KNOWLEDGE/SKILLS/ABILITIES** + Analyze risk score… more
- Prime Therapeutics (Madison, WI)
- …every decision we make. **Job Posting Title** Senior Business Analyst - Medicaid Implementations - Remote **Job Description** The Business Analyst (BA) Senior will ... execute on medium projects as a liaison among business operations, technology groups, clients, business partners, vendors, and project/program team to understand, analyze, and facilitate business needs, requirements, and impacts of business changes as a result… more
- CVS Health (Madison, WI)
- …initiatives to support audit readiness and collaborates with Compliance, Legal, Medicaid Health Plans, Network Contracting, and Provider Relations to ensure ... alignment with regulatory and contractual obligations. The Lead Director will also serve as a key liaison between Compliance, Legal, Network Contracting, and Provider Relations teams. **Required Qualifications** + A minimum of 7 years of healthcare payer… more
- Molina Healthcare (WI)
- …We are seeking a highly skilled and forward-thinking Big Data Engineer to join our healthcare data team. This role encompasses the end-to-end design, development, and ... management of large-scale data systems tailored for healthcare analytics. The ideal candidate will be responsible for architecting and maintaining robust, scalable, and secure data pipelines that support critical decision-making across the organization. This… more
- Humana (Madison, WI)
- …may include national clinical guidelines, CMS policies and determinations, Medicaid state contracts, clinical reference materials, internal teaching conferences, and ... Behavioral Health Medical Directors will learn Medicare, Medicare Advantage and Medicaid requirements, and will understand how to operationalize this knowledge in… more
- Good Samaritan (WI)
- …and support to all operating segments across Sanford. Responsible to review Medicare/ Medicaid documentation to assist nursing centers in completing minimum data set ... (MDS) documentation to assure appropriate levels of Medicare and/or Medicaid reimbursement. Works with executive leadership, administrators, and facility staff in… more
- Molina Healthcare (WI)
- …Assists and executes tasks and projects to ensure Centers for Medicare & Medicaid Services (CMS) and State regulatory requirements are met for Pre-pay Edits, ... Care Organization (MCO) or health plan setting, including experience in Medicaid and/or Medicare, or equivalent combination of relevant education and experience… more
- Humana (Madison, WI)
- …ensure successful submission and reconciliation of encounter submissions to Medicaid /Medicare. Ensures encounter submissions meet or exceed all compliance standards ... and develops tools to enhance the encounter acceptance rate by Medicaid /Medicare. Looking for long-term improvements of encounter submission processes. Begins to… more
- Prime Therapeutics (Madison, WI)
- …management. Enforces teamwork across all internal departments, as well as with Medicaid Clients, and an in-depth understanding of all rebate programs, trends, and ... state laws and standards of practice which govern the Medicaid Drug Rebate Program. + Ensures compliance with each...Drug Rebate Program. + Ensures compliance with each State Medicaid contract. + Maintains rebate records in accordance with… more
- Molina Healthcare (Milwaukee, WI)
- …and processing. This role will focus on identifying, reviewing, and validating Medicaid secondary payments to ensure alignment with internal configuration rules and ... adjudication, QNXT system navigation, and strong analytical acumen. Experience in Medicaid managed care is required, and a background in payment integrity-either… more
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