- Molina Healthcare (Madison, WI)
- …Enrollment activities (along with other Core Ops areas of responsibilities) within Medicare and Medicaid. Role is predicated on building relationships with vendors, ... Level Agreements between the parties. **Job Duties** + Develops Medicare and Medicaid vendor strategies aligned with CMS and...for additional vendor funding as required. + Oversee the review , reconciliation, and approval of invoices for payment of… more
- Molina Healthcare (Madison, WI)
- …and expertise in the performance of prior authorization, inpatient concurrent review , discharge planning, case management and interdisciplinary care team activities. ... Medical Directors + Develops medical policies and procedures + Conducts peer review **JOB QUALIFICATIONS** **REQUIRED EDUCATION:** * Doctorate Degree in Medicine *… more
- Molina Healthcare (Kenosha, WI)
- …and/or pharmacy internal monitors who support processes involved with the review of non-formulary drugs or other drugs requiring prior authorization. + ... speed to answer, and average hold time are compliant with Centers for Medicare and Medicaid Services (CMS) regulations. + Ensures that adequate staffing coverage is… more
- Molina Healthcare (Madison, WI)
- …internal compliance program, including annual, periodic, focal, etc. audits. * Request, review and perform oversight of internal corrective action plans (CAPs) for ... it relates to the finding. * Performs support via review and approval for Corporate Operations policies, procedures, guidelines...years or more + 5 years of experience in Medicare , DSNP and CSNP population, Enrollment, A&G, Claims, Compliance,… more
- CVS Health (Madison, WI)
- …to members and providers. As a Medical Director you will focus primarily on review appeal cases for denied medical services. This includes First Level Appeals / ... Second Level Appeals / Expedited Appeals / Appeal Hearings / Special Projects and Committee participation when needed. The Medical Director will provide clinical, coding, and reimbursement expertise as well as directing case management when necessary. The… more
- St. George Tanaq Corporation (Madison, WI)
- …Experience and Skills** + Must have 2-3 years of medical dispute resolution or Medicare appeals, medical review , clinical, or related experience in a healthcare ... clear, concise, and impartial and supports the determination made, and documents review + Makes sound, independent decisions based on medical evidence in accordance… more
- Evolent (Madison, WI)
- …provider and vendor contracting, compliance, population health (including utilization management), Medicare , and Medicaid. + Draft, review and negotiate ... President, Deputy General Counsel, the Attorney will prepare and review a variety of complex contracts and provide legal...of legal terms to promote efficiency. + Draft and review significant correspondence and other documents on behalf of… more
- Humana (Madison, WI)
- …group practice management. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or ... and other sources of expertise. Medical Directors will learn Medicare and Medicare Advantage requirements, and will...daily work. The Medical Director's work includes computer based review of moderately complex to complex clinical scenarios, … more
- Humana (Madison, WI)
- …group practice management. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or ... internal teaching conferences, and other reference sources. Medical Directors will learn Medicare and Medicare Advantage requirements, and will understand how to… more
- Humana (Madison, WI)
- …group practice management. + Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or ... of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. Begins to influence department's… more