- Evolent (Madison, WI)
- …provides clinical rationale for standard and expedited appeals. + Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD ... review process to reflect appropriate utilization and compliance with...by any state or federal health care program, including Medicare or Medicaid, and is not identified as an… more
- Evolent (Madison, WI)
- …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 (Madison, WI)
- …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
- Prime Therapeutics (Madison, WI)
- …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
- Walgreens (Weston, WI)
- …billing and submission of claims to government-sponsored health care programs, including Medicare , Medicaid, and all other third-party payers, as well as the ... bodies and contracts with payers and pharmaceutical manufacturers (BOP, DEA, Medicare , accreditation bodies, compounding, FDA, etc.). + Complies with all federal… more
- Veterans Affairs, Veterans Health Administration (Middleton, WI)
- …claims for billing purposes ensuring eligibility and referring questionable coding for review . Submit claims to 3rd party health Insurance Carriers, with knowledge ... of Medicare coverage benefits. Interprets third party insurance policies and...billing purposes ensuring eligibility and referring questionable coding for review . Interprets insurance policies and requirements for billing. EXPERIENCE:… more
- Prime Therapeutics (Madison, WI)
- …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
- Conduent (WI)
- …Enrollment, Eligibility, Invoicing, Claims, and related topics **. ** Fully explain the Medicare Part D and or Part C Medicare Advantage Programs. Answering ... members issue by answering their questions. Navigate the Members' plan benefits, review Client's policy and procedures, while using resources provided by the Client… more
- Option Care Health (Milwaukee, WI)
- …expert in health care compliance including, but not limited to FWA, Medicare & Medicaid billing requirements, and interactions with healthcare professionals. Lead or ... of appropriate policy into the development of programs, including oversight and/or review and approval of programs and processes with our business teams and… more
- Humana (Ashland, WI)
- …face-to-face visits and monthly phone contacts. + Participate in the development and ongoing review and coordination of the member's plan of care. + Take the lead in ... continuously improving consumer experiences **Preferred Qualifications** **Prior experience with Medicare & Medicaid recipients** + Previous experience with electronic… more