- 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
- Actalent (Fort Lauderdale, FL)
- …review Utilization management InterQual Milliman Commercial Guidelines Medicaid Medical management Medicare Managed care Patient care Medical record Case ... Actalent is hiring a Utilization Management Nurse! Job Description The Utilization Management...and Milliman Criteria. Knowledge of Florida Medicaid Program and CMS Guidelines. Proficient in word processing software, spreadsheet software… more
- 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
- 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
- UHS (Winston Salem, NC)
- …Vineyard Behavioral Health is seeking a talented and dynamic Director of Risk Management to join our team of dedicated healthcare professionals! At Old Vineyard ... The Joint Commission and certified by the Centers for Medicare and Medicaid Services. We are passionate about our...passion. We are currently seeking a Director of Risk Management to join our talented and caring team. Our… more
- 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
- UHS (Temecula, CA)
- …also demonstrate the knowledge of principles of utilization management and case management as well as regulatory compliance standards ( CMS , Title 22, TJC). ... to achieve certification as a Gluten-Free Food Service facility, 3 Star Medicare Hospital Compare Rating, the American College of Cardiology Chest Pain Center… more
- 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
- Renown Health (Reno, NV)
- Position Purpose This position consistently applies the utilization management process as required by CMS including the use of designated criteria for primary ... review. Incorporates into the utilization management process the ability to access and interpret clinical...insurance plans, Medicare Advantage Plans, Centers for Medicare and Medicaid Services ( CMS ) and Division… more
- LA Care Health Plan (Los Angeles, CA)
- …or CM. Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services( CMS ) requirements for health plan compliance with UM ... safety net required to achieve that purpose. Job Summary The Utilization Management (UM) Admissions Liaison RN II is primarily responsible for receiving/reviewing… more
- 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
- 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
- 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
- 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
- Macpower Digital Assets Edge (Los Angeles, CA)
- …Care Services (DHCS), Department of Public Social Services (DPSS), Centers for Medicare and Medicaid Services( CMS ), CalHers, and National Committee for Quality ... regulatory audits. This position will develop, with the assistance of CSC management , a successful auditing strategy for the following end-to-end processes within… more
- Stratis Group (Fort Worth, TX)
- …and/or Teams Advanced knowledge of medical insurance terminology Knowledge of Centers of Medicare & Medicaid Services ( CMS ) policies and processes with expertise ... the entire access process which may include formulary coverage/utilization management criteria, coding, insurance forms & procedures, benefits investigation, prior… more
- Better-Health-Group (Tampa, FL)
- …have a strong background in Quality and HEDIS processes related to Medicare Advantage, Traditional Medicare , Medicaid, and Commercial healthcare programs, with ... all relevant regulations and guidelines related to Quality and HEDIS, including CMS and NCQA standards. Monitor changes in regulatory requirements and industry best… more
- Inova (Falls Church, VA)
- …other prestigious recognitions which include: a five star rating from the Centers for Medicare and Medicaid Services ( CMS ), being named by IBM Watson Health as ... Experienced Social Worker Case Manager to join the Case Management Team. This role will be PRN Day shift,...shape a more compassionate future for healthcare. Inova Health System is an Equal Opportunity employer. All qualified applicants… more
- Hospital for Behavioral Medicine (Worcester, MA)
- …ICD-10 coding, claim formatting, and payer-specific requirements Ensure compliance with CMS , Medicare , Medicaid, and commercial payer billing guidelines Review ... and correct claim errors using system -generated reports and payer feedback Perform follow-up activities on...years' experience in facility billing experience with knowledge of Medicare DDE and computerized systems strongly preferred, or related… more
- NYC Health Hospitals (New York, NY)
- …(ASHP), Institute for Safe Medication Practices (ISMP) and Centers for Medicare /Medicaid Services ( CMS ) medication-related and pharmacy practice standards and ... Life Possible NYC Health + Hospitals is the largest public health care system in the United States. We provide essential outpatient, inpatient and home-based… more
