- Molina Healthcare (St. Petersburg, FL)
- …with the Service Level Agreements between the parties. **Job Duties** + Develops Medicare and Medicaid vendor strategies aligned with CMS and State regulations, ... **Job Summary** This position is responsible for the holistic management of the external vendor relationships for Claims and Enrollment activities (along with other… more
- Humana (Tallahassee, FL)
- …radiology, and genetics.** + Knowledge of the managed care industry including Medicare Advantage and Managed Medicaid. + Utilization management experience in ... a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. + Experience with national guidelines… more
- BAYADA Home Health Care (Orlando, FL)
- …for quality and adherence to policies and procedures. As a member of the Medicare Case Management (MCM) office, individuals in this role are expected to ... to the OASIS and ICD 10 coding while using the Medicare PDGM billing model and CMS guidelines. + Review and communicate OASIS edit recommendations to each… more
- Humana (Tallahassee, FL)
- …team to assist and facilitate new hires and remediation of medical directors performing Medicare utilization management processes and be the liaison for the ... key enterprise leader, with responsibility for evolving Humana's Utilization Management of medical review by physician or nurse, with...or nurse, with a focus on our 5+ million Medicare members. You will also facilitate the delivery of… more
- Actalent (Sunrise, FL)
- …Utilization management + InterQual + Milliman Commercial Guidelines + Medicaid + Medical management + Medicare + Managed care + Patient care + Medical record ... Actalent is hiring a Utilization Management Nurse! Job Description The Utilization Management...Milliman Criteria. + Knowledge of Florida Medicaid Program and CMS Guidelines. + Proficient in word processing software, spreadsheet… more
- Molina Healthcare (St. Petersburg, FL)
- …** **Summary** Safeguard member trust and plan compliance by owning Molina's entire CMS Complaints Tracking Module (CTM) life cycle. As Director of CTM Oversight & ... issues, steer partners toward durable fixes, and convert disciplined CTM management into Stars gains, audit readiness, and measurable member-experience improvements.… more
- Humana (Tallahassee, FL)
- …practice management + Utilization management experience in a medical management review organization, such as Medicare Advantage and managed Medicaid + ... by diverse resources which may include national clinical guidelines, CMS policies and determinations, Medicaid state contracts, clinical reference materials,… more
- Molina Healthcare (Jacksonville, FL)
- …Summary** Responsible for leading, organizing and directing the activities of the Medicare Contracted Provider Post-Pay Claim Appeals and Disputes in accordance with ... the standards and requirements established by the Centers for Medicare and Medicaid. **Knowledge/Skills/Abilities** * Leads, organizes, and directs the activities of… more
- Molina Healthcare (St. Petersburg, FL)
- …average speed to answer, and average hold time are compliant with Centers for Medicare and Medicaid Services ( CMS ) regulations. + Ensures that adequate staffing ... for review. + Assures that activities and processes are compliant with CMS and National Committee of Quality Assurance (NCQA) guidelines and Molina policies… more
- Prime Therapeutics (Tallahassee, FL)
- …Medicaid Services ( CMS ) compliance compliant + Utilize Prime's MTM process management system to record member specific information + Assess beneficiary ... all lines of business to support the Centers for Medicare & Medicaid Services ( CMS ) Star and... system operations (eg workflow processes and case management ) + Government programs ( Medicare ) knowledge **Preferred… more