• US Citizen

• Green Card

• EAD (OPT/CPT/GC/H4)

• Corp-Corp

• Consulting/Contract

• UG :- - Not Required

• PG :- - Not Required

• No of position :- ( 1 )

• Post :- 25th Aug 2022

•             Recent Healthcare experience

•             Medicare Advantage job experience at a Healthcare Payer

•             Experience in Government Healthcare Medicare Advantage (MA) OR Experience configuring Altruista's Guiding Care application

 

 

Key Areas of Responsibility:

 

•             Learn Medicare Advantage (MA) systems, applications, and processes

•             Implement new Medicare Advantage clients

•             Gather MA business requirements from new clients

•             Healthcare Payor knowledge and expertise to recommend best practices on Medicare Advantage, and/or ACA implementations and operational workflow. 

•             Responsible for creating and training on Policies and Procedures and Job Aids

•             SME on Claims payment platforms such as Health Rules, Facets and/or QNXT or SME on Altruista’s Guiding Care/OICS application configuring Care Management, Disease Management, Population Health, Utilization Management and Appeals and Grievance modules.

•             SME in one of the following capabilities: Membership/Enrollment, Customer Service, Provider, Claims, Premium Billing, Finance or Clinical

•             Document and improve MA processes

•             Develop MA test plans and documents test data based on specifications

•             Review MA system enhancements/changes and identifies issues to the standard system and other processing components

•             Objectively evaluate the MA activities and systems within specific area for process evaluation and makes recommendations for simplification

•             Guide coworkers in problem resolution related to documented procedures as well as various systems and/or connectivity issues

•             Develop MA Policies and Procedures (P&Ps), Job Aids, and Standard Operating Procedures (SOPs)

•             Develop MA end user training materials

•             Train and rollout MA systems and processes

•             Prepares verbal and written communication regarding changes, procedures, projects, and implementations

•             Completes necessary reporting for analysis using applicable programming, software, and/or reporting tools

 

Key Desired Skills, Experience and Knowledge:

 

•             Bachelor's degree

•             5+ years of Medicare Advantage job experience at a Healthcare Payer

•             5+ years’ experience in Government Healthcare Medicare Advantage (MA)

•             3+ years of configuring Altruista's Guiding Care application

•             Experience with MA Claims

•             Experience with MA Eligibility

•             Experience with MA Open Enrollment (OE)

•             Experience with MA Utilization Management (UM)

•             Experience with MA Finance and Billing, and Premium Billing

•             Experience with MA Appeals & Grievances (A&G)

•             Experience with the Affordable Care Act (ACA)

•             Experience working with CMS.  Strong knowledge of Medicare rules and regulations preferred.

•             Preferred experience with Guiding Care, Facets, QNXT and/or HealthRules Claims Platforms

•             Medicare Advantage customer service a plus

•             Training experience a plus

•             Medicaid experience not necessary, but a plus

•             Comprehensive knowledge of business support and systems concepts including data movement.  Ability to work with and translate needs to developers

•             Ability to communicate effectively with technical and non-technical audiences, including the ability to express complex data and system integration concepts to management, peers, and the business units

•             Strong communication and interpersonal skills

•             Strong analytical and conceptual skills

•             In-depth understanding of user acceptance test plans and test matrices, project plans, and scope and design documents