- MyFlorida (Tallahassee, FL)
- 68059454 - MEDICAID MANAGEMENT REVIEW MONITOR Date: Jun 6, 2025 The State Personnel System is an E-Verify employer. For more information click on our ... No: 854649 Agency: Agency for Health Care Administration Working Title: 68059454 - MEDICAID MANAGEMENT REVIEW MONITOR Pay Plan: Career Service Position… more
- MyFlorida (Tallahassee, FL)
- …activities for quality review , utilization management and quality monitoring and review of specific types of Medicaid services in order to assist in ... and planning entity. The Agency is responsible for administering the Florida Medicaid program, the licensure and regulation of nearly 50,000 health care facilities,… more
- Prime Therapeutics (Tallahassee, FL)
- …+ 8 years of relevant client services experience in healthcare or pharmacy benefit management , preferably in Medicaid . + 5 years of leadership / people ... drives every decision we make. **Job Posting Title** Senior Director Clinical Account Management - Remote **Job Description** The Sr Director of Clinical Account … more
- MyFlorida (Fernandina Beach, FL)
- …Serves as the County Health Department's Group Security Administrator for Florida Medicaid Management Information System (FLMMIS) Medicaid Access for ... The primary responsibility of this position is to provide management and coordination of all operational aspects of the...Monitor the preparation of all Patient, Third Party, Medicaid , Medicare, and HMO billing and receipt of payments… more
- MyFlorida (Tallahassee, FL)
- …(eg, CMS guidelines, Florida Statutes) *Knowledge of IT systems, such as Medicaid Management Information Systems (MMIS), health information exchanges (HIE), or ... the FX Governance structure. Interfaces with business units, Enterprise Project Management Office, and Strategic Enterprise Advisory Services vendor for the purpose… more
- Healthfirst (FL)
- **Duties/Responsibilities:** + Oversees utilization management functions which include timely authorizations related to pre-certification, concurrent review , ... reviews medical charts to obtain additional information required for appropriate utilization management and to solve complex clinical problems + Allocate, monitor… more
- MyFlorida (Fort Lauderdale, FL)
- …and processing changes of ownership in APD iConnect. The Work You Will Do Review incoming Medicaid Waiver provider application packets and notify applicant of ... subtleties of group dynamics. This position with APD will serve staff and management across the Agency. Your work will impact the workplace culture, our community,… more
- Elevance Health (Tampa, FL)
- …and determines appropriate area to refer or assign case (utilization management , case management , QI, Med Review ). + Monitor and manage case ... and documents all actions. + Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical… more
- Evolent (Tallahassee, FL)
- …mission. Stay for the culture. **What You'll Be Doing:** **Clinical Rules Management , Analyst** Seeking a detail-oriented **Clinical Rules Management , Analyst** ... the accuracy and integrity of our clinical rule engine, impacting our clinical review and recommendations for thousands of patients every day. This role will be… more
- Molina Healthcare (FL)
- …practice. + Utilizes IT and data analysts to produce tools to report, monitor and improve Utilization Management . + Actively participates in regulatory, ... development, provider contracting experience. + Experience with NCQA, HEDIS, Medicaid , Medicare and Pharmacy benefit management , Group/IPA practice,… more
- Prime Therapeutics (Tallahassee, FL)
- …business (Employer Markets, Health Insurance Marketplace (HIM), Commercial, Medicare, and Medicaid ). This individual is the primary relationship and contract owner ... for their assigned account/s and oversees a cross-functional account management team, including representation across all lines of business, and key departments such… more
- Molina Healthcare (Tampa, FL)
- …performance, as well as team trends that may require implementing process improvements. + Monitor and review case management dashboards and error reports to ... is responsible for reviewing and resolving member grievances, regulatory complaints, Medicaid Fair Hearings and communicating resolution to members or authorized… more
- Prime Therapeutics (Tallahassee, FL)
- …notifications, and periodic reports related to licensed functions (Pharmacy Benefit Management (PBM), Third Party Administrator, Utilization Review Organization, ... their designated areas. This role partners with key internal stakeholders to monitor aspects of compliance and validate policies, procedures, licensure, and program… more
- MyFlorida (Fort Lauderdale, FL)
- …subtleties of group dynamics. This position with APD will serve staff and management across the Agency. Your work will impact the workplace culture, our community, ... collaborating with external stakeholders including the Quality Improvement Organization (QIO), Medicaid Program Integrity (MPI) and the Medicaid Fraud Control… more
- MyFlorida (Daytona Beach, FL)
- …subtleties of group dynamics. This position with APD will serve staff and management across the Agency. Your work will impact the workplace culture, our community, ... collaborating with external stakeholders including the Quality Improvement Organization (QIO), Medicaid Program Integrity (MPI) and the Medicaid Fraud Control… more
- MyFlorida (Fort Lauderdale, FL)
- …and administrative code and train staff regarding these. Comply with and monitor compliance (when applicable) of the mandatory requirements of section 215.422, ... effect budget amendments to the approved operating budget. Create, monitor and update the CHD spending plan and maintain...to navigate the budget. The incumbent is required to review assigned program budgets and OCA balances monthly and… more
- Prime Therapeutics (Tallahassee, FL)
- …external vendor and our clients. The Vendor Program Manager will handle the management of vendor solutions, showcasing the value of those solutions to the market. ... Partner with outsourced vendor and Prime internal resources to monitor and ensure all processes are working to provide...within the vendor suite of solutions + Responsible to review dashboard and provide timely reporting of all required… more
- Prime Therapeutics (Tallahassee, FL)
- …notifications, and periodic reports related to licensed functions (Pharmacy Benefit Management (PBM), Third Party Administrator, Utilization Review Organization, ... their designated areas. This role partners with key internal stakeholders to monitor aspects of compliance and validate policies, procedures, licensure, and program… more
- Prime Therapeutics (Tallahassee, FL)
- …subject matter expert (SME) with underwriters, other areas of Prime, and senior management on pricing initiatives, data analyses, and the Request For Proposal (RFP) ... process + Lead, manage, and review data analyses, reporting, and projections + Lead, manage,...+ Present results and analyses to key stakeholders, senior management , and clients; answer detailed and challenging questions regarding… more
- Datavant (Tallahassee, FL)
- …and support value-based client delivery across Medicare Advantage, ACA, and Medicaid programs. The ideal candidate combines deep healthcare analytics expertise with ... strong product management skills, and thrives at the intersection of product,...impact, client value, and strategic alignment. + Define and monitor KPIs such as suspecting accuracy, chart throughput, RAF… more