• NORTH EAST MEDICAL SERVICES (Burlingame, CA)
    …to align UM strategies and ensure compliance with CMS , DHCS, and Medicare Advantage program requirements. 2 . Case Management (CM): Support and guide ... Collaborate with health plan partners to align QI strategies and ensure compliance with CMS , DHCS, and Medicare Plan requirements. Work closely with the Quality… more
    Upward (07/09/25)
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  • Optum (San Antonio, TX)
    …their inquiries. Routes calls to appropriate department if necessary Follows system scripting and validates member demographic information Documents the provider or ... appropriate Provides support to internal staff, subcontractors and providers with respect to Medicare drug related issues May serve as a subject matter expert for… more
    Upward (07/25/25)
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  • Optum (San Antonio, TX)
    …inquiries. Routes calls to the appropriate department if necessary Follows system scripting and validates member demographic information Documents the provider or ... Provides support to internal staff, subcontractors and providers with respect to Medicare drug related issues Participates in and contributes to the overall pharmacy… more
    Upward (07/07/25)
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  • Optum (San Antonio, TX)
    …their inquiries. Routes calls to appropriate department if necessary Follows system scripting and validates member demographic information Documents the provider or ... appropriate Provides support to internal staff, subcontractors and providers with respect to Medicare drug related issues May serve as a subject matter expert for… more
    Upward (07/11/25)
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  • Children's National Hospital (Silver Spring, MD)
    …Reimbursement Analyst will be responsible for preparing and filing the annual Medicare and Medicaid cost reports, audit support, third party settlement analysis, ... in the healthcare industry Required Skills/Knowledge Strong knowledge of Medicare and Medicaid reimbursement regulations for hospitals and/or physician payment… more
    Upward (07/17/25)
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  • Blue Cross Blue Shield of Arizona (Phoenix, AZ)
    …job Develop recommendations for innovation to existing clinical services to improve management of medical utilization and costs and using data to design, develop, ... and support implementation of clinical operations management programs as approved by Clinical Excellence leadership to meet the demographic and epidemiological needs… more
    Upward (07/27/25)
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  • SCAN (Long Beach, CA)
    …member of SCAN Health Plan, one of the nation's leading not-for-profit Medicare Advantage plans, serving more than 285,000 members in California, Arizona, Nevada, ... Specialist II is responsible for ingesting accurate provider data into SCAN's IKA system and ensures that all provider data related requests from the Medical Group… more
    Upward (07/26/25)
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  • Pearl Health (New York, NY)
    …intelligence, and making care delivery more efficient and sustainable. The Center for Medicare and Medicaid ( CMS ) is launching a new value-based care program ... years of clinical experience in a healthcare setting in chronic care management , preferably for Medicare beneficiaries. Insurance experience preferred. Strong… more
    Upward (07/07/25)
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  • USA Clinics Group (Northbrook, IL)
    …completing initial and subsequent credentialing packages as required by Medicare and Medicaid, commercial payers, hospitals, and regulatory agencies. Position ... provider's CAQH database file timely according to the schedule published by CMS Apply for and renew annually all provider licenses; Professional, DEA, Controlled… more
    Upward (06/30/25)
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  • Molina Healthcare (Long Beach, CA)
    …contracted provider network. They are responsible for network management including provider education, communication, satisfaction, issue intake, access/availability ... staff to determine; for example, non-compliance with Molina policies/procedures or CMS guidelines/regulations, or to assess the non-clinical quality of customer… more
    Upward (07/27/25)
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  • Jupiter Medical Center (Jupiter, FL)
    …counties to receive a 4-star quality and safety rating from the Centers for Medicare & Medicaid Services ( CMS ). Education High School Graduate or Equivalent ... job. While this is intended to be an accurate reflection of the current job, management reserves the right to revise the job or require that other or different tasks… more
    Upward (07/27/25)
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  • Intermountain Healthcare (Salt Lake City, UT)
    …that reviews are completed and in compliance with Select Health, NCQA, and CMS guidelines. 5. Maintains the confidentiality of members' personal information to be ... services. 9. Maintains primary care physician (PCP) assignments for Medicaid and Medicare members and ensure PCP compliance. Assigns PCP's for high utilizers on… more
    Upward (07/27/25)
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  • Strategic Staffing Solutions (Detroit, MI)
    …HAS AN OPENING! Strategic Staffing Solutions is currently looking for a Business Analyst ( CMS Regulations / Risk) for a contract opportunity with one of our largest ... Analyst who can bridge regulatory requirements with operational execution across Medicare Advantage and other risk-bearing programs. The analyst will help ensure… more
    Upward (07/17/25)
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  • Trinity Health (Livonia, MI)
    …1-3 years of claims, adjusting, or billing experience preferred. Experience with Medicare reimbursement rules and CMS -1500 & UB-04 claims preferred. Previous ... with third-party billers. Manage fee schedules in the software system . Communicates with Interdisciplinary teams regarding unauthorized services. Submit enrollments,… more
    Upward (07/17/25)
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  • Takeda Pharmaceutical Company Limited (Exton, PA)
    …Ensure submission of pricing information within the statutory time frames - Centers for Medicare & Medicaid Services ( CMS ), state agencies as required by statute ... Legal, and Internal Audit to ensure compliance with the Medicare Modernization Act of 2003, the Deficit Reduction Act...Improvement Act. Keep up to date on all applicable CMS releases relating to pricing calculations; Partner with Commercial… more
    Upward (07/11/25)
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  • Stamford Health (Stamford, CT)
    …Report has recognized Stamford Hospital as a High-Performing Hospital. The Centers for Medicare and Medicaid Services ( CMS ) rated Stamford Hospital as a ... phone/customer service skills. Knowledge of office equipment operation, (EMR, telephone system , fax machine, copy machine, etc.). Ability to handle sensitive and… more
    Upward (07/26/25)
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  • Mindlance (Nashville, TN)
    …(eg, agencies, brokers). *Review submitted materials to ensure compliance with CMS Medicare Marketing Guidelines, applicable regulations, and MultiPlan brand ... compliance, or Medicare Advantage/PDP marketing review preferred. *Familiarity with CMS Medicare Marketing Guidelines and regulations. *Strong attention to… more
    Upward (07/23/25)
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  • WMC Health (Hawthorne, NY)
    …in compliance with detailed requirements, guidelines, and deadlines of Centers for Medicare & Medicaid Services, National Committee for Quality Assurance (NCQA) in ... Staff Office by identifying, initiating, monitoring, and maintaining Medicaid and Medicare enrollment requirements. Ensure proper attention is given to all assigned… more
    Upward (07/14/25)
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  • Stamford Health (Stamford, CT)
    …Report has recognized Stamford Hospital as a High-Performing Hospital. The Centers for Medicare and Medicaid Services ( CMS ) rated Stamford Hospital as a ... Job Description Stamford Health is a well-established, award-winning Healthcare System with multiple locations in CT. We are seeking to hire several Part Time… more
    Upward (07/25/25)
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  • Alternate Solutions Health Network (Kansas City, MO)
    …CARE for our patients like they are our own FAMILY. Note: The Centers for Medicare & Medicaid Services ( CMS ), in collaboration with the Centers for Disease ... Control and Prevention (CDC), require COVID-19 vaccinations for all Medicare and Medicaid certified providers. Based on this regulation, all of our employees must be… more
    Upward (07/23/25)
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