Surveillance and Utilization Review Specialist Job at Gainwell Technologies LLC
Be part of a team that unleashes the power of leading-edge technologies to help improve the health and well-being of those most vulnerable in our country and communities. Working at HMS, a Gainwell Company carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work flexibility, learning, and career development. You’ll add to your technical credentials and certifications while enjoying a generous, flexible vacation policy and educational assistance. We also have comprehensive leadership and technical development academies to help build your skills and capabilities.
Summary
HMS, a Gainwell Technologies Company
HMS is hiring Surveillance and Utilization Review (SURS) Specialists for our Alaska MMIS Fiscal Agent account. These positions is expected to work accurately under minimal direction to maintain update and distribute monthly provider appeal and Lock In appeal logs, prepare agency summaries and all related documentation for fair hearings, coordinate all utilization review (UR) appeal requests, maintain and update the suspect provider report, update and distribute required reports. Review and reports monthly on sanctions limiting payment and licensing board disciplinary actions related to KMAP providers. Act as contact person for KDHE legal, Medicaid Fraud Control Unit (MFCU), and all outside agencies regarding UM fraud issues. Assist grievance and appeal coordinator with processing grievances, appeals, and fair hearings. Operates as Lock In Program coordinator and contact person for members in restrictive assignment program. Work with UR team to coordinate member reviews, prepare Lock In Program assignments when determination is made, notify members and providers, and maintain system assignments. Review and adjudicate claims suspended related to Lock In editing. Responsible for Lock In and appeal-related monthly statistics, peer review Lock In review cases.
Your role in our mission
Formulate and define system scope and objectives using knowledge of information technology and industry knowledge/ requirements.- Act as a liaison between client and technical solutions/ support groups, using strong communication skills to elicit, document, analyze and validate business processes, systems, and solution requirements.
- Research, identify, and specify solutions to problems.
- Document requirements specifications using high-maturity methods, processes and tools.
- Support requirements management and change management processes.
- Support aspects of the business cycle, including proposals, feasibility studies, and implementations.
- Consider the business implications of the application of technology to the current business environment.
What we’re looking for
Knowledge of criminal investigation, auditing and accounting procedures.- Minimum of two years Medicaid experience or other health care experience. Knowledge and/or experience in the legal field.
- Experience in Fraud and Abuse preferred.
- Ability to read, understand, and interpret complex regulatory and procedural documents.
- Strong analytical skills. Strong oral/written communication skills. Time Management and organizational skills.
What you should expect in this role
Anchorage, AK preferred will consider AK remote
#LI-NB1
#LI-ONSITE
The pay range for this position is $85,000.00 - $106,300.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at HMS, a Gainwell Company. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.
We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with HMS, a Gainwell Company, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about HMS, A Gainwell Technologies Company at our company website and visit our Careers site for all available job role openings.
HMS, a Gainwell Company is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.
Please Note :
clarksqn.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, clarksqn.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, Site.com is the ideal place to find your next job.