- Evolent (Trenton, NJ)
- …available, within the regulatory timeframe of the request. + Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review ... utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance… more
- Prime Therapeutics (Trenton, NJ)
- …benefit design and pricing support for all Prime's lines of business (commercial, Medicare and Medicaid). This role will also provide actuarial support in complex ... support, and maintain financial and complex actuarial models + Lead, perform, and review data analyses, reporting, and projections + Lead, perform, and review … more
- WTW (Fort Lee, NJ)
- …leading direct-to-consumer insurance services business, specializing in the distribution of Medicare Advantage, Medicare Supplement and Life & Supplemental ... that partner-run campaigns meet TRANZACT's quality and compliance standards. + Regularly review and audit partner activities for adherence to guidelines. **6. Daily… more
- Prime Therapeutics (Trenton, NJ)
- …design and pricing support for all Prime's lines of business (commercial, Medicare and Medicaid). **Responsibilities** + Build, support, and maintain financial and ... actuarial models + Perform and review data analyses, reporting, and projections...healthcare organization or PBM + Previous experience pricing Commercial, Medicare or Medicaid lines of businesses + 1 year… more
- Aveanna Healthcare (Mount Laurel, NJ)
- …matched with patients based on the specific needs and care requirements. + Review and validate employee work schedules and shifts to ensure accuracy in time ... levels, adjusting schedules based on workload and demand. + Assess and review field staff scheduling and opportunities to maximize caregiver availability. +… more
- CVS Health (Florham Park, NJ)
- …Formulary Analyst, you will perform a critical role in the analysis of Medicare and Commercial formularies to determine client eligibility for rebates with respect ... by manufacturers and clients. + Adhering to quality control process in review of formulary rebate eligibility and contributing to enhancing our quality control… more
- Prime Therapeutics (Trenton, NJ)
- …Subject Matter Expertise in their areas of focus (Affordable Care Act, Medicare , Medicaid, Corporate Compliance, Compliance Assessment or Services etc.) + Develop ... procedures (Standard Operating Procedures, Desk Top Procedures, etc.) and review applicable operations teams' documentation; develop regulatory monitoring and… more
- Healthfirst (NJ)
- …CMS and New York State regulations, job aides and HF policies. This includes review of performance audit reports in order to maintain superior and accurate care data ... programs such as MAP or MLTC + Knowledge of Medicare Regulations related to Long Term Care + Experience...care plan + Understanding of health plans such as Medicare , Medicaid and/or Managed Long-Term Care Plan (MLTCP) +… more
- Virtua Health (Lumberton, NJ)
- …adhere to standards as set forth by health system. Assist with review /change of policies and procedures to reflect current regulations and best practices. ... or ambulatory medical setting. Knowledge of insurance (ICD-9 CPT coding, Medicare regulations, state regulations, CLIA, DOH, and OSHA regulations) preferred. Solid… more
- Otsuka America Pharmaceutical Inc. (Trenton, NJ)
- …territory plans through partnerships with internal and external stakeholders + Review and educate offices on payer policies, including prior authorization ... in rare disease + Strong knowledge of Centers for Medicare & Medicaid Services (CMS) policies and processes, especially... & Medicaid Services (CMS) policies and processes, especially Medicare Part D + Experience in "Buy and Bill"… more