- 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
- 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
- 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
- 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
- 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
- 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
- Tenet Healthcare Corporation (Detroit, MI)
- …support post-acute needs , j) timely complete and concise documentation in Case Management system , k ) maintenance of accurate patient demographic and insurance ... Tenet policy *Completes timely, complete and accurate documentation in the Tenet Case Management system to communicating information to the care team and provide… 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
- Alignment Healthcare (Greensboro, NC)
- …enrollment kit fulfillment, certification and contracting/appointment requirements. 7. Ensures CMS compliance with all sales, enrollment processes and events. 8. ... managing relationships apprised of any updates and/or changes within department, CMS guidelines, company policies and procedures while keeping strong morale intact.… more
- Top Tier Reps LLC (Chico, CA)
- …Drug Enforcement Agency (DEA) number or proof of application Meets Centers for Medicare & Medicaid Services ( CMS ) criteria to billMedicare Current AHA-HCP CPR ... hire Drug Enforcement Agency (DEA) number or proof of application Meets Centers for Medicare and Medicaid Services ( CMS ) to bill Medicare Credentialed… 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
- Hallmark Business Connections (Kansas City, MO)
- …payers, knowledge of the Medicare Advantage market and familiarity with CMS five-star quality rating system . Experience in marketing automation, direct mail, ... close deals that help Healthcare payers improve member retention and Star ratings within Medicare Advantage and DSNP Plans. Your focus will be on driving new logo… 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
- 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
- PacificSource (Portland, OR)
- …of the Senior Medical Director, the Medical Director is responsible for the management of the PacificSource Commercial, Medicare , and Medicaid Lines of Business. ... coverage for pre- or post-service requests in accordance with evidence-based guidelines, CMS coverage guidelines to include the Medicare Benefit Policy Manual,… more
- MJHS (New York, NY)
- …affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of ... Program (PSLF) Responsibilities: Community Health Coach will conduct in-person care management visits to identify and provide appropriate interventions based on the… 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
