Medicaid Appeals And Grievance Associate Manager Jobs

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Risk Management is charged with protecting company assets. This group is responsible for minimizing risk – in legal, financial and operational areas – and its affects on the organization, as well as for enforcing security and safety measures. Coordinate effective resolution of member and/or provider/practitioner appeals, complaints and grievances. Responsible for the day-to-day management of staff to ensure effective resolution of member or provider/practitioner appeals, complaints and grievances for all products, which may contain multiple issues and, may require coordination of responses from multiple business units. Ensure timely, customer focused response to appeals, complaints and grievance. Responsible for day-to-day implementation of Aetna's appeals, complaints and grievances policies and procedures. Identifies trends and issues; reports on and recommends solutions. Accountable for meeting the financial, operational, and quality objectives of the unit. -Manages team's productivity and resources, communicates productivity expectations and balances workload to achieve customer satisfaction through prompt/accurate handling of customer concerns. -Serves as a content model expert and mentor to team regarding Aetna's policies and procedures, regulatory and accreditation req

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Aetna Better Health is Aetna’s Medicaid managed care plan. Backed by over 30 years of experience managing the care of those with a broad array of health care needs, our Medicaid plans have demonstrated that getting the right help when you need it is essential to better health. That’s why Aetna® Medicaid plans include the guidance and support needed to connect our members with the right coverage, resources, and care. We are focused on enhancing quality and population health outcomes while integrating CVS assets to bring accessible healthcare to our members. Aetna Better Health of Maryland is seeking an experience leader with vast operational knowledge of Medicaid for its state-wide managed Medicaid business in the role of Chief Operations Officer (COO). The COO role will be strategic and committed to developing colleagues as well as relentlessly pursuing change that is best for the organization and its customers. The COO role will collaborate with the CEO to develop the strategic vision of the Health Plan, policies & procedures, and operational objectives including leading RFP readiness efforts. The COO will oversee high level strategic and operational activities of various plan functional areas which include traditional service operations (Claims, Provider Services, Information Technology, Grievance & Appeals and Member Services) as well as Medical Management (Quality, Netw

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary: Ready to take your Medical Director career to the next level with a Fortune 6 company? Join Aetna, a CVS Health company, and make a meaningful impact on the health and well-being of Medicaid members across the country. Aetna operates Medicaid managed care plans in Arizona, Florida, Illinois, Kentucky, Louisiana, Maryland, Michigan, New Jersey, New York, Ohio, Oklahoma, Pennsylvania, Texas, Virginia, and West Virginia. We are seeking a Medical Director to join our centralized Medical Management team. This work-from-home position will primarily support Aetna Better Health of Louisiana , while also providing support across the other health plans as needed. In this role, you will partner with Medical Management staff to ensure timely, consistent, and clinically sound decisions for members and providers. Key responsibilities include: Utilization Management and medical necessity reviews Prior authorization and precertification determinations Concurrent review for inpatient and outpatient services Acute and post-acute care reviews Peer-to-peer consultations with treating providers Pharmacy reviews and first-level appeal determinations Collaboration with multidisciplinary clinical and operational teams The Medical Director also participates in a rotating on-c

Medical Director - Medicaid Appeals — 26 Locations. Apply via Workday.

Become a part of our caring community The Business Intelligence Lead serves as the primary analytics and enrollment operations expert supporting Medicaid Enrollment. This role is responsible for leading state implementation readiness efforts, regulatory and contractual reporting support, enrollment analytics, compliance monitoring, and analytics modernization across Medicaid markets. The Business Intelligence Lead solves complex business problems and operational challenges using internal and external data sources to provide actionable insights and strategic direction to business leaders. This role serves as the primary analytics lead supporting Medicaid Enrollment Operations initiatives, with responsibility for state implementation readiness, enrollment analytics, compliance monitoring, and scalable solution architecture. This associate functions as a strategic individual contributor and internal consultant, partnering with business leaders, operational teams, compliance organizations, and technology partners to design and implement analytics solutions. The Business Intelligence Lead exercises independent judgment and decision-making authority on complex issues affecting state compliance, enrollment operations, contractual reporting obligations, membership reporting, reconciliation processes, and operational performance. The role leverages modern analytics platforms including Databricks, Power BI, SQL, and cloud-based data environments to create reusable and scalable solutions supporting current and future Medicaid market expansions. This associate is expected to influence strategy, identify opportunities for operational efficiencies, establish reporting standards, and drive modernization efforts that reduce implementation effort while improving compliance, operational visibility, and business outcomes. Use your skills to make an

Louisiana Medicaid Inbound Contact Representative — Louisiana. Apply via Workday.

Indiana Medicaid Inbound Contact Representative — Indiana. Apply via Workday.

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Ready to take your clinical skills to the next level? Check out this outstanding opportunity for a Medicaid Prior Authorization Pharmacist with Aetna! This is a Clinical Pharmacist position supporting Medicaid Prior Authorization. An active TX or AZ pharmacist license that is in good standing is required. New hire is required to obtain the secondary license (AZ or TX) within 90 days of hire . We are hiring for the 10:30 am - 7:00 pm CST shift (post training). The training schedule is: 10:00 am - 6:30 pm CST. You will be required to work one Saturday every 4-6 weeks and occasional holidays. This is a fully remote position open to qualified candidates within the United States who currently hold active, unrestricted TX or AZ pharmacist licensure. Required Qualifications - Active and unrestricted TX and/or AZ pharmacist license - New hire is required to obtain the secondary license (AZ or TX) within 90 days of hire . - Demonstrated experience with clinical decision-making while applying evidence-based clinical guidelines/criteria; utilizing formularies/preferred drug lists. - Experience working in a high production, remote team environment - 3+ years experience working as a pharmacist or completion of PGY1 managed care residency, includin

Become a part of our caring community Humana Healthy Horizons is looking for a Value-Based Programs Lead who will support successful value-based provider relationships with a focus on improving the provider experience and achieving path-to-value goals. You will lead the beginning-to-end operational support of specialty Medicaid value-based payment (VBP) models in alignment with segment strategy and goals. The Value-Based Programs Lead will be a subject matter expert in VBP and have advanced technical knowledge and experience. Develop new innovative VBP models for range of provider types, such as behavioral health, maternity, specialists, and social determinants of health, creating glide paths to move providers from volume to value. Align scope of work with roadmap for new VBP model development to ensure compliance with Medicaid contractual requirements and RFP commitments. Analyze financial, utilization, and performance data to identify opportunities to drive improvements in quality and/or reductions in total cost of care. Creation of VBP payment strategies and model design, such as developing payment model logic, performance metrics and benchmarks, and financial terms, which align with segment goals. Design and contribute to development of provider reporting packages to help providers understand their overall and detailed performance. Partner with finance team to conduct impact analysis and modeling for new VBP models. Collaborate with team members and matrixed teams to operationalize and rollout of new VBP models. Contribute to developing solutions to operational gaps. Monitor VBP model performance KPIs to identify opportunities to enhance model design based on internal and external feedback and performance data. Ability to translate strategy into models that can be piloted and scaled across markets. <

Senior Manager – Aetna Medicaid Controllership COE — RI - Cumberland. Apply via Workday.

Proposal Quality Analyst (Medicaid) — Work At Home-Ohio. Apply via Workday.

Strategic Project Manager - Medicaid Capture Management — Remote Nationwide. Apply via Workday.

Senior Provider Contracting Professional - Behavioral Health/Medicaid — Remote Nationwide. Apply via Workday.

Provider Contracting Professional (Behavioral Health/Medicaid) — 3 Locations. Apply via Workday.

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary: As a Senior Manager of Medicaid Compliance, you are responsible for the management, execution, and oversight of the compliance program activities and deliverables of a Medicaid managed care organization operating in a moderately complex regulatory environment. This role will allow you to serve as the designated Compliance Officer for Aetna’s Michigan (MI) Medicaid health plan. You will oversee the activities of other compliance team members assigned to the MI market. You will be responsible for developing and maintaining systems and processes that demonstrate the principles of an effective Compliance program and promote compliant and ethical behavior in the assigned Medicaid health plan. Responsibilities include, but are not limited to: Acts as the primary liaison to the state Medicaid agency, facilitating compliance and contract-related communications and activities Maintain the systems and tools to track, monitor, review, and submit required regulatory and compliance related deliverables and responses to state Medicaid agencies on or before required due dates; independently prepares and oversees the submission of complex regulatory reports and deliverables as needed on behalf of the Medicaid compliance team Facilitates the preparation for and management of external audits conducted by state Medicaid and related agencies or partners in conjunction wit