Medicaid Appeals And Grievance Associate Manager Jobs

Become a part of our caring community The Senior Quality Improvement Professional leads efforts to improve clinical quality and provider performance for the Humana Healthy Horizons in South Carolina Medicaid Plan. You will develop and implement cross-functional quality improvement initiatives, evaluate business processes and performance outcomes, and drive sustainable, measurable improvements. Reporting to the Quality Improvement Director, you will collaborate with internal and external stakeholders to advance a provider-focused culture of quality and performance excellence. You will manage complex projects and analyze diverse data sources to identify opportunities, inform strategy, and support organizational objectives. The Senior Quality Improvement Professional leverages data to lead quality improvement initiatives, monitor performance metrics, and support provider performance enhancement. This role collaborates with provider-facing teams to implement targeted interventions, develop educational resources, and drive achievement of quality and member experience goals. The position leads and participates in multidisciplinary committees, provides strategic clinical guidance on quality initiatives, and influences business decisions through data-driven insights. Operating with a high degree of independence, the Senior Quality Improvement Professional manages complex projects, exercises sound judgment, and recommends solutions to advance organizational objectives. Essential Role Responsibilities The Senior Quality Improvement Professional is responsible for improving clinical quality and performance outcomes among South Carolina network providers. Key responsibilities include: Partner with Provider Engagement, Network, and Contracting teams to implement clinical quality improvement strategies including education, training and performanc

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. Join a high-performing actuarial team supporting CVS Health and Aetna's exciting and growing Medicaid business. Support CVS Health's financial integrity by leading actuarial forecasting with sound practices to meet the business needs and ensure reasonable actuarial projections. A Brief Overview The primary focus of this director role will be leading actuarial support for the financial forecast modeling of the Medicaid line of business with a secondary focus on trend analysis & development. This role will primarily provide oversight and leadership of activities related to forecasting with a secondary focus on trend normalization and projection. Fundamental Components Primary Role (70% time): Lead budget and forecast storytelling for the Medicaid business. Oversee forecast model development and improvement, and support plan actuaries in understanding forecast projections. Drive forecast related analysis including development of key assumptions, evaluation of financial experience and trend drivers. Review budget and forecast from a business perspective and ensure sound actuarial projections. Identify and support process improvement through automation and process simplification; assure timely and accurate deliverables. Manage high visibility and complex projects. Allocate and align resources. Se

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. Location Bureau County or surrounding area. Program Overview Help us elevate our patient care to a whole new level! Join our Aetna team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our members who are enrolled in Medicare and Medicaid and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members’ health care and social determinant needs. Join us in this exciting opportunity as we grow and expand dually eligible members to change lives in new markets across the country. Position Summary/Mission Our Care Managers are frontline advocates for members who cannot advocate for themselves. They are responsible for assessing, planning, implementing, and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member’s overall wellness. Fundamental Components & Physical Requirements Develops a proactive plan of care to address identified issues to enhance the short and long-term outcomes as well as opportunities to enhance a member’s overall wellness. Uses clinical to

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 We are seeking an experienced actuarial professional to support Medicaid managed care pricing evaluation, financial performance management, and strategic decision-making. This role requires a strong combination of actuarial expertise, business acumen, technical proficiency, and leadership capability. The successful candidate will serve as a key partner to market leadership, finance, and operational stakeholders while providing guidance and oversight to actuarial analysts supporting complex Medicaid markets. This position is ideal for an actuary with strong project management skills who can balance short-term deliverables and ad hoc requests with long-term strategic initiatives, thrive in a dynamic environment, and independently develop analyses to address emerging business questions. Medicaid Pricing and Actuarial Analysis • Lead actuarial evaluation of state capitation pricing and forecasting for Medicaid managed care programs. • Evaluate and interpret complex state rate-setting methodologies, risk adjustment programs, acuity adjustments, and regulatory requirements. • Assess revenue, medical cost, utilization, and margin drivers to identify emerging trends and business risks. • Summarize and communicate actuarial analysis for business leadership. Strategic Business Support • Partner with market, product, finance, and operations tea

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 The Supervisor of Service Operations will maintain oversight of a team of claim processors and all claim related functions for Medicaid Claim Operations. We are seeking a highly motivated individual who will establish a clear vision aligned with company values and team goals. The claim Supervisor works with staff to align daily processing activities to successfully meet Health Plan metrics. Responsibilities will include: Managing a team of claim processors and overseeing daily operations for assigned health plan to achieve state required metrics. Manage employee performance and development. Identifies risks and barriers and collaborates with business partners to improve processes. Coaches and mentors team members, assisting with complex questions and customer interactions. Acts as liaison between staff and other areas, communicating workflow results, ideas, and solutions. Completes various business reports, including tracking, trending and results. Works with the Medicaid leadership team to allocate resources to meet volume and performance standards. Builds a cohesive team through collaboration, inclusion, and diverse thinking. Ability to work in a fast-paced production environment. Required Qualific

Become a part of our caring community The Transition Coordinator (Care Coach 2) evaluates member's needs and requirements. This evaluation aims to achieve and/or maintain an optimal wellness state. The Coordinator does this by guiding members/families toward resources and facilitating interaction with them. These resources are appropriate for the care and wellbeing of members. The Care Coach 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. Position Responsibilities: Support the ongoing member transitions in and out of the Indiana Medicaid programs, the Contractor's enrollment, and among care settings. Complete transitions and assists with the planning and preparation for them, and the follow-up care after. Works with the Member Advocate Coordinator and other member-focused departments of the plan. This collaboration ensures continuity and coordination of care and member and provider communication through the initial transition, ongoing benefit plan, and MCE transfers. Ensure the transfer and receipt of all outstanding prior authorization decisions, utilization management data, and clinical information such as prevention and wellness programs(s), care management and complex case management notes. Help with transitions from the custodial setting to the home and community-based setting. We ask that you have telephonic and in-person meetings within an assigned region. The purpose of these meetings is to work with various stakeholders, including long-term care members, hospital/rehab staff discharge planners, family members/POA's, PCP's, and other healthcare professionals. The ultimate goal is to prevent custodial placements whenever possible. Assess and evaluate member's needs to establish a member specific car

Become a part of our caring community Humana is a publicly traded, Fortune 60 health benefits company with a long history of successful innovation and reinvention. It has transformed itself from the largest US nursing home company in the ’60s, to the largest US hospital corporation in the ’80s, to a leading health benefits company beginning in the ’90s. Today, Humana is a leader in consumer-focused health solutions and is one of the largest health benefits organizations in the country. The Enterprise Growth Strategy team is a newly created organization supporting growth across Humana’s businesses. The team has a strong dotted-line partnership with the Medicare and Medicaid organization, Humana’s largest, which comprises over 80% of the company’s total revenue and the majority of its earnings. Team members partner with the senior leaders of the business unit, and more broadly with leaders throughout the enterprise, as they deliver strategy projects addressing some of the businesses’ most important opportunities and challenges. These high-profile strategy projects place the team at the forefront of helping to define the future of Humana’s largest businesses. Humana is seeking an experienced team member to support delivering some of Medicare and Medicaid’s highest priority projects and initiatives, with an emphasis on Medicare Advantage strategy development. As a Manager, you will deconstruct issues and challenges, perform targeted research and analysis, and craft sound, logical solutions and recommendations. You will also shape implementation considerations, and work with business owners as appropriate to transition analysis into execution. While doing so, you will have the opportunity to collaborate with fellow team members, subject matter experts, members of Humana’s executive Management Team, and corporate, functional, and business unit leaders. </s

Become a part of our caring community The Telephonic Quality Outreach Professional supports the EPSDT program requirements in a telephonic outreach environment by evaluating member needs and helping families achieve or maintain an optimal state of wellness. The Telephonic Outreach Care Coach Professional 1 performs basic administrative/clerical/operational/customer support/computational tasks. Typically work on straightforward moderate complexity assignments that are routine and structured in nature. The Telephonic Quality Outreach Professional employs a variety of strategies and techniques to coordinate services and resources that facilitate HEDIS gap closure and improve pediatric health outcomes. The supervisor limits decisions to defined parameters around work expectations, quality standards, priorities and timing, and supervises closely and/or works within established policies/practices and guidelines with minimal opportunity for deviation. Position Responsibilities: Telephonic outreach to close HEDIS gaps for Medicaid pediatric population Assist members in addressing barriers to care, including scheduling challenges and transportation needs, to support access to primary care and overall well-being Collaborate with EPSDT Senior Quality Improvement Professional and Coordinator related to strategic outreach to maximize HEDIS outcomes Collaborate with other departments Provide vaccine awareness and education following Bright Futures and EPSDT preventive health guidelines Empower member independence through education and outreach that promote ongoing self-sufficiency in managing preventive and primary care needs Other responsibilities as assigned Use your skills to make an impact Required Qualifications Unrestricted Licensed Practical Nurse (LPN) in

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. Do you have a passion for engaging with people and helping them on their journey to better health? Discover a meaningful role where you’ll engage with health plan members primarily online, helping to close gaps in care. Signify Health, part of CVS Health®, is hiring full-time, board-certified nurse practitioners or physician assistants to conduct Video Visits for Medicare Advantage, Medicaid, and certain commercial plan members. During our Video Visits, you’ll conduct an approximately 30-minute visit, including a medication and medical history review, allowing time to educate members about their health and answer their questions. In this role, you will: Conduct online “Video Visits” with health plan members, working in a private space with adequate internet connection Be part of our efforts to visit millions of people nationwide with the goal of providing connections to the right care for people’s unique needs Provide 40 hours of availability weekly, consistently providing 320&#43; capacity units per month Execute a strong visit completion rate, consistently pacing 220&#43; completed visits per month Maintain training, affiliation, and compliance with Video Visit requirements (regular training required) Other role expectations and requirements: Be trained and credenti

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 - Supports comprehensive coordination of Medicaid and/or Medicare pharmacy services including intake and processing of pharmacy authorization requests. - Promotes and supports quality effectiveness of healthcare and Pharmacy Services. - Evaluates, authorizes approval, and communicates decisions for pharmacy requests according to clinical guidelines. - Evaluates and authorizes approval of pharmacy requests received by telephone, facsimile, and/or other means using client clinical criteria. - Determines appropriateness for medications. Communicates decision to physicians, physician’s office staff, medical management staff, members, and/or pharmacists. - Will perform clinical research to support request. - Performs non-medical research including eligibility verification, COB, and benefits verification. - Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements. - Process requests in compliance with various laws and CMS regulations and company policies and procedures. - May communicate with Aetna Case Managers, Health Plan Staff, External Pharmacies and Health Care Providers. - Promotes communication, both internally and externally, to enhance effectiveness of medication therapy management services. - Sedentary work involving significant periods of sitting, tal

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. ***The ideal candidate will reside in larger New York area*** Position Summary The Senior Manager, Financial Planning and Analysis role will function as the Financial Planning and Analysis lead the New York Medicaid Health Plan and will support the CFO directly to achieve financial and strategic goals by managing and driving business actions and financial goals across the Plan. This position will oversee the development, analysis, and reporting of financial forecasts, budgets, and key performance metrics to support strategic decision-making. This role ensures alignment of financial strategies with state Medicaid requirements and corporate goals, providing actionable insights to executive leadership and cross-functional teams. With significant budget oversight and authority, the position drives financial performance, manages operational complexities, and assesses opportunities to enhance profitability and efficiency in a dynamic healthcare environment. Key interactions include executive leaders, operational managers, and state Medicaid stakeholders. The Senior Manager will: Oversee the development of comprehensive financial reports that align with strategic goals. Leads the identification of key financial variances and trends, providing insights for strategic decisions. Lea

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. Do you have a passion for engaging with people and helping them on their journey to better health? Discover a meaningful role where you’ll engage with health plan members primarily online, helping to close gaps in care. Signify Health, part of CVS Health®, is hiring full-time, board-certified nurse practitioners or physician assistants to conduct Video Visits for Medicare Advantage, Medicaid, and certain commercial plan members. During our Video Visits, you’ll conduct an approximately 30-minute visit, including a medication and medical history review, allowing time to educate members about their health and answer their questions. In this role, you will: Conduct online “Video Visits” with health plan members, working in a private space with adequate internet connection Be part of our efforts to visit millions of people nationwide with the goal of providing connections to the right care for people’s unique needs Provide 40 hours of availability weekly, consistently providing 320&#43; capacity units per month Execute a strong visit completion rate, consistently pacing 220&#43; completed visits per month Maintain training, affiliation, and compliance with Video Visit requirements (regular training required) Other role expectations and requirements: Be trained and credenti

Become a part of our caring community The HR Business Partner 2 leads the people management agenda in a business unit/area, and acts as a facilitator for the company's management team. Applies broad experience in various Humana Resources (HR) areas of expertise. The HR Business Partner 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The HR Business Partner 2 acts as a single point of contact for the employees and managers in the business unit/area in the Medicaid RFP Response and Implementation team and their people management agenda. Possesses a deep knowledge of the business unit / area, key employees and business processes. Builds a strong business relationship with the business unit/area and transfers HR requests and solutions to/from the business unit. Implements best practices and supports the delivery of HR processes at the business unit/area. Identifies gaps, proposes and implement changes necessary to cover risks. Acts as the performance improvement driver and provokes positive changes in the people management. Leads the change management projects and manages the HR related internal and external communication. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures. This position will focus primarily on the HR related activities tied to a response for RFPs and the subsequent stand up of new business. The position will work across the HR organization to build, run and analyze data in support of RFPs and stand up of new business and ensure the alignment and timing of resources key to the operational stand up of

Job Title Sales, Territory Manager - RespirTech (Houston) Job Description RespirTech’s Territory Manager represents the InCourage airway clearance therapy medical device, calling on but not limited to Pulmonologists to support patients with chronic respiratory and neuromuscular conditions on a journey to better breathing. Your role: Executing outside sales and territory management, inclusive of account management and new business development. Employing a hunter mentality to identify new opportunities, overcome objections and change the mindsets of prescribers, while achieving performance growth goals. Performing total office sales calls, in-services on patient profiles, product demonstrations and presenting clinical evidence to physicians. Being an expert on Medicare, Medicaid and private insurance coverage-criteria for InCourage vest therapy, while effectively educating healthcare teams in identifying patients who meet coverage criteria. Obtaining medical record documentation in order for coverage to be obtained. Analyzing data to effectively target priority healthcare teams and create sales call routing. Capable to be flexible and adjust routing to fit pipeline management needs. You're the right fit if: You’ve acquired 3&#43; years of successful direct field sales, clinical education or clinical sales support experience. Previous durable/home medical equipment and/or pharmaceutical sales experience preferred. Your skills include: Ability to be in the field within your territory 90% (some territories may include overnights). The ability to build and maintain strong customer relationships. You have a Bachelor’s Degree in Business Administration, Marketing, Sales or equivalent (preferred) or 7&#43; years of field sales experience. You must be able to successfu

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. Job Purpose and Summary: Accountable for Commercial, Medicare, Exchange and Medicaid NCQA Accreditation quality projects and initiatives through design, development, and implementation. This role focuses primarily on Delegated Credentialling and Oversight of the delegated Credentialling organizations, per contract. Proactively builds strong business relationships with internal and external business partners. Participates in presentation to business partners on accreditation requirements to achieve results and ensure accreditation readiness. Proven experience as a subject matter expert on NCQA accreditation standards, analysis, Delegated Credentialing file reviews and supporting quality functions. Primary Job Duties & Responsibilities: Utilizes statistical analysis, data visualization tools, and database queries to identify trends, patterns, and opportunities for quality improvement. Develops and maintains performance metrics and dashboards to track and report on patient safety, clinical effectiveness, patient experience, and compliance with quality standards. Contributes to quality improvement projects and initiatives by providing data-driven insights and recommendations. Collaborates with cross-functional teams to design and implement evidence-based practices, care protocols, and process improvements. Assists in conducting audits and performing chart review