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This role is responsible for translating federal and state Medicaid requirements, health plan business needs, and operational workflows into detailed functional requirements that support system configuration, data integration, reporting, and compliance.
The Analyst will partner closely with business stakeholders, IT teams, vendors, and external partners to ensure Medicaid systems and solutions meet contractual, regulatory, and operational expectations.
Position Responsibilities: · Medicaid Business & Regulatory Analysis o Analyze federal and state Medicaid regulations, contract requirements, and policy guidance, and translate them into clear business and functional requirements o Support Medicaid program areas such as eligibility, enrollment, claims, encounters, care management, provider management, quality, and compliance o Interpret CMS, state agency, and contractual changes and assess operational and system impacts · Technical Requirements & Solution Design o Develop detailed functional and technical requirements, including use cases, process flows, data mappings, interface specifications, and system configuration needs o Collaborate with IT, data, and vendor teams to design and validate technical solutions that align with Medicaid business needs o Support system enhancements, defect resolution, and new implementations across core Medicaid platforms (e.g., claims, encounters, care management, data warehouse) · Data & Integration Support o Analyze data flows between Medicaid systems, vendors, and external entities (state agencies, CMS, providers) o Support reporting, analytics, and regulatory submissions (e.g., encounter data, quality measures, financial reporting) o Assist with data validation, reconciliation, and root-cause analysis for Medicaid data issues · Stakeholder & Cross-Functional Collaboration o Serve as a liaison between Medicaid business teams, IT, finance, compliance, and external vendors o Facilitate requirements workshops, design sessions, and stakeholder reviews o Clearly communicate complex technical concepts to nontechnical stakeholders and business priorities to technical teams · Testing & Implementation Support o Support system testing activities, including test planning, test case development, and user acceptance testing (UAT) o Validate that solutions meet Medicaid business and regulatory requirements prior to deployment o Support golive activities and postimplementation issue resolution · Documentation & Governance o Maintain clear, auditready documentation of requirements, decisions, and approvals o Ensure alignment with Medicaid governance, SDLC, and change management processes o Support audits, regulatory reviews, and compliance inquiries, as needed Position Qualifications: · 5+ years of experience as a Business Analyst, with direct Medicaid or healthcare payer experience · Strong understanding of Medicaid programs, managed care operations, and state/federal compliance requirements · Experience translating business requirements into technical specifications · Experience working with IT teams, system vendors, and data/reporting teams · Strong analytical, documentation, and problem-solving skills · Experience supporting Medicaid managed care organizations (MCOs) or state Medicaid programs preferred · Familiarity with Medicaid healthcare payer systems such as claims platforms, encounter processing, care management systems, or eligibility/enrollment platforms preferred · Experience with data analysis, SQL, or data warehouse concepts preferred · Knowledge of CMS reporting, state encounter submissions, or quality programs preferred · Experience with Agile, SAFe, or traditional SDLC methodologies preferred · A minimum of a Bachelor’s Degree in Business, Information Systems, Health Administration, Public Health, or other related field .
Remote working/work at home options are available for this role.
Healthcare Partner — Strategic Growth Opportunity
VCG Attorney Recruiting | South Florida | Hybrid
A dynamic and highly respected Florida-based firm is seeking a partner-level Healthcare Partner to join its growing practice.
This is an opportunity for attorneys who want to practice at a high level without the bureaucracy often found in large firms, while still benefiting from a sophisticated platform, strong infrastructure, and meaningful support for business development.
The firm has built a reputation for excellent legal work, collaborative culture, and entrepreneurial energy. Attorneys are encouraged to take ownership of their practices while benefiting from cross-collaboration, mentorship, and a strong institutional platform.
Hybrid work flexibility is available with meaningful in-office collaboration.
The Practice
This position focuses on healthcare regulatory and transactional matters, including work with healthcare providers, healthcare systems, and healthcare businesses navigating complex regulatory environments.
Representative matters include:
• Healthcare regulatory compliance (federal and state)
• Medicare and reimbursement issues
• CMS and government enforcement matters
• Transactions involving healthcare entities
• Healthcare mergers and acquisitions
• Corporate practice of medicine issues
• Integrated delivery systems
• Joint ventures and healthcare business structures
• Operational and regulatory counseling for healthcare organizations
Clients may include:
• Physician group practices
• Large healthcare providers and health systems
• Skilled nursing and long-term care facilities
• Clinical laboratories
• Home health agencies
• Medical device manufacturers
• Durable medical equipment suppliers
• Management service organizations (MSOs)
• Practice management companies
• Substance abuse treatment centers
Who We're Speaking With
• Partner-level attorneys or senior attorneys ready to step into a partner role
• Attorneys with significant healthcare regulatory and transactional experience
• Lawyers comfortable advising sophisticated healthcare organizations
• Attorneys interested in growing or maintaining a book of business
• Attorneys seeking a collaborative platform with strong infrastructure and flexibility
Experience with Medicare, CMS, government enforcement agencies, or managed care organizations is a plus.
Why This Is Different
This opportunity is ideal for attorneys who want:
• A high-quality legal platform without BigLaw bureaucracy
• Meaningful support for building and maintaining a book of business
• Direct client relationships and leadership opportunities
• A collaborative environment where performance and personality both matter
• Flexibility to grow their practice within a supportive firm culture
The firm is known for attracting BigLaw attorneys seeking sophisticated work with a better quality of life.
Confidential Conversations Welcome
This is not a one-off job pitch.
We take a career strategy approach, discussing:
• Whether this platform fits your long-term goals
• How your practice could grow within the firm
• Strategic positioning in the Florida healthcare market
• Compensation structure and practice support
All conversations are strictly confidential.
Remote working/work at home options are available for this role.
Our client is a fast-scaling digital media company working alongside major global entertainment brands. With deep expertise in large-scale content operations, platform monetization, rights management, and localization they enable partners to unlock the full commercial potential of their video catalogs and reach global audiences at scale.
The role owns senior-level client relationships, drives platform monetization strategy, and acts as a key commercial advisor to executive stakeholders across high-impact global accounts. It’s a highly visible position with full commercial ownership, strong growth potential, and direct exposure to leadership
What You’ll Do :
- Own and expand strategic client partnerships with full commercial responsibility, driving revenue growth, performance, and long-term value creation,
- Act as the primary commercial decision-maker and senior point of contact across assigned high-impact global accounts,
- Lead monetization and distribution strategies across major digital platforms, including YouTube and Facebook,
- Optimize commercial performance across platforms by leveraging data, analytics, and platform-specific best practices,
- Generate strategic insights using YouTube Analytics and CMS data, translating complex data into clear, executive-level presentations,
- Advise clients on content strategy, rights utilization, localization, and multi-territory distribution to maximize global reach and revenue,
- Partner closely with internal operations, analytics, rights, and content teams to ensure seamless execution at scale,
- Identify and unlock new growth opportunities across content catalogs, territories, formats, and monetization models.
Skills Required:
- 7+ years of experience in strategic account management, partnerships, or commercial roles within digital media, entertainment, or content-driven businesses,
- Strong expertise in platform monetization, analytics, and CMS-driven content operations,
- Solid understanding of content localization, rights management, multi-territory distribution, and audience development,
- Proven ability to communicate data-driven strategies and commercial insights to senior and executive-level stakeholders,
- A strong ownership mindset with a commercially focused, results-driven approach,
Why this role :
- Operate at the intersection of content, data, rights, and monetization,
- Own high-visibility, high-revenue global entertainment portfolios with direct business impact,
- Work in a company that combines deep operational expertise with strategic leadership,
- Be part of a fast-scaling organization shaping the future of digital video monetization and global distribution
Associate Director of Member Engagement & Enablement
Associate Director of Member Engagement Enablement
1) deeply understand our members
2) set our member engagement and experience strategy, including the measures of performance that drive value, both enterprise-wide and for key strategic initiatives
3) provide the support, guidance and insights to help the business achieve those levels of performance;
4) partner with enterprise technology to build and manage the next generation of member engagement capabilities and infrastructure; and
5) operationalize our member engagement programs by coordinating across clinical, service, analytics, marketing, enterprise technology to deliver seamless member engagement interventions that produce measurable impacts and resonate in the market.
Reporting to the Vice President of Member Engagement, Experience, and Advocacy, the Director of Member Engagement Enablement is responsible for supporting the team’s charter by delivering on the 4th pillar. This person will partner deeply with enterprise technology to help scope, design and build the next generation of our consumer engagement infrastructure, leveraging the insights and needs of the entire MEEA team – especially member engagement programs and consumer research and performance measurement – as well as those of the broader organization to helps us advance our core member engagement-driven strategic imperatives, which includes member navigation.
Key responsibilities include:
- Lead the consumer experience and engagement ‘enablement’ strategic portfolio project work project:
- Be the day-to-day business lead for the staged build of our core member engagement operational data platform
- E.g. ensure the phasing aligns with our strategic business needs and use cases, aware of interdependencies with other projects, vendors and partners in their own phases of development
- E.g. ensure all business use cases and needs across the organization are understood, represented and included for prioritization and then explaining the business rationale behind prioritization decisions to all stakeholders
- Be the day-to-day business lead for our email/SMS
- Design and advance future consumer engagement enablement strategic projects
- In support of our current and developing member engagement programs, and in partnership with the Associate Director of Member Engagement Programs, lead the work to ensure seamless data flow and integration across various engagement platforms including but not limited to CRM, omni-channel communication orchestration engines, and analytics platforms.
- Evaluate and consider emerging tools such as (AI, personalization engines, CRM/CMS innovations) for relevance and scalability
- For example, partner with the Associate Director of Member Engagement Programs and colleagues in Performance Measurement and Improvement (PMI) and Health and Medical Management to evaluate new machine learning and CenAI algorithms/tools that identify key points on members’ clinical journeys, the most impactful opportunities for navigation/guidance/intervention and how to prioritize across multiple clinical pathways when a member has multiple conditions, as well as factoring in other key interactions with BCBSMA to maximize relevance, strengthen our relationship with the member and increase the impact of engagement.
- Champion and prioritize AI, automation and self-service functions across all relevant domains and purviews above.
Qualifications:
- Bachelor’s degree required
- Minimum 10 years of experience in health-related technology roles, with a strong preference for health plan experience and the deep understanding of health plan core technologies, data structures, formats and uses (for BCBSMA this means working knowledge and/or use of: DAL/CAR, RTMS, EDI, EAH, MSST and Data warehouse
- Preferred areas of specialization include (but not limited to): consumer experience and/or digital and marketing technologies; health plan analytics and performance measurement (actuarial, consumer experience, provider performance)
- Deep understanding of the marketing, service and CX technology landscape, including CRM, and email/SMS tools, and customer data technologies.
- Familiarity with agile methodologies and experience embedding agile practices in business teams
- Experience with corporate strategy and portfolio processes
- Strong technical expertise and acumen, with a demonstrated ability to deliver business value through technology
- Proven track record of delivering business-focused results through cross-functional partnerships across a matrixed organization
- Ability to generate trust, influence, and build alliances with dependent stakeholders and business partners.
- Excellent leadership and staff management skills
- Experience communicating and visualizing complex and abstract concepts as well as story-tell to all levels/knowledge-levels in a way that resonates.
Work Location: Remote
Assignment Duration: 14+ Weeks
Work Arrangement: Remote
Position Summary:
* This position serves as a clinical and administrative subject matter expert for Part C and Part D grievance and appeal functions; investigating and identifying member, provider and/or claim processing appeals and customer service grievances issues; and ensuring that investigation, resolution and responses are processed promptly in accordance with CMS requirements and timelines.
Key Responsibilities:
* Maintains a thorough understanding of our organization operations and business unit processes, work flows and system requirements, including, but not limited to, plan benefits as outlined in the Explanation of Coverage (EOC) documents, authorizations, referrals, network and non-network provider claims, and regulatory compliance.
* Maintains a current knowledge of CMS rules and regulations relating to the grievance and appeal processes.
* Participates in CMS and other audits and related activities as required.
* Coordinates investigation and resolution of complex grievance and appeal issues, reviews information provided by members, providers, and other interested parties regarding grievance and appeal cases, collects and analyzes supporting documentation, and makes the appropriate decisions involving grievance and appeal determinations.
* Performs all assigned functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides an excellent service experience to internal and external customers by consistently demonstrating our core and leadership behaviors each and every day.
* The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
* Perform all other duties as assigned.
Qualification & Experience:
* Working knowledge of CMS Managed Care Manual Chapter 13 - Beneficiary Grievances, Organization Determinations, and Appeals and CMS Prescription Drug Benefit Manual Chapter 18 - Part D Enrollee Grievances, Coverage Determinations, and Appeals, knowledge of healthcare billing and claims adjudication processes.
* Familiarity with medical terminology, ICD, CPT, HCPCS, and DRG codes, accurate and efficient keyboarding skills, and the ability to work effectively with common office software.
* Math, communications and business skills normally demonstrated by a high school degree or equivalent.
* Demonstrated ability to evaluate and interpret medical records and health plan benefit documents to make appropriate benefit determinations.
* Must possess highly developed interpersonal skills and communications skills, with a strong customer service orientation.
* 5 years of work experience with CMS member services, prior authorizations, appeal and grievance, or claims functions.
* Associate's Degree in a healthcare field of study or Nursing Diploma.
* Licensed Practical Nurse or Registered Nurse with a current, active, unrestricted nursing license in the state of Arizona (a state in the United States).
This role is ideal for pharmacists with prior authorization, managed care, or PBM experience who thrive in a structured, remote setting.
As a Clinical Pharmacist Advisor, you will review pharmacy benefit requests, make clinical determinations, and ensure compliance with CMS and Medicare guidelines while delivering best-in-class service.
Key Responsibilities Review and process prior authorizations, coverage determinations, and appeals Evaluate clinical documentation to support approval/denial decisions Ensure all cases meet Medicare Part D and CMS compliance standards Conduct provider outreach to obtain additional clinical information Document all decisions clearly and accurately in system workflows Manage high-volume queues while meeting productivity and quality metrics Apply clinical knowledge using drug compendia and established guidelines Required Qualifications Active Pharmacist license in state of residence (in good standing) PharmD or Bachelor’s Degree in Pharmacy Strong computer skills (Excel, Word required; Access, PowerPoint, Visio preferred) Experience with data entry, dual screens, and multiple systems Ability to work independently in a productivity-driven remote environment Strong attention to detail and documentation accuracy Preferred Experience Managed Care / PBM experience Prior Authorization, Coverage Determinations, or Appeals Medicare Part D knowledge and CMS guideline familiarity Remote pharmacist or high-volume review experience Retail + Managed Care hybrid background Schedule & Training Requirements Training: Monday–Friday, 9:00 AM – 5:30 PM EST (first 8 weeks – no time off allowed) Post-Training Schedule: Business Hours: 7:00 AM – 8:00 PM EST (Mon–Fri) Weekends: 7:00 AM – 4:30 PM EST Must be flexible to work assigned 8-hour shifts, including weekends Work Environment Requirements (MANDATORY) Dedicated, quiet, private workspace Wired internet connection: Minimum 25 Mbps download / 5 Mbps upload Speed test screenshot required (must be included on resume) Ability to remain on camera during training and team meetings Ability to sit and focus for full shift with minimal interruptions Submission Requirements (MUST BE INCLUDED ON RESUME) Screenshot of internet speed test ( ) Screenshot of active pharmacist license (showing name, state, expiration) Completed candidate questionnaire (see below) Candidate Pre-Screen Questionnaire (Include with Submission) Are you available for full-time training (M–F, 9–5:30 EST) for 8 weeks with no time off? Can you work any assigned 8-hour shift between 7 AM – 8 PM EST, including weekends? Do you have a dedicated, quiet workspace for remote work? Do you have wired internet meeting 25/5 Mbps requirements? Can you sit and focus for the entire shift without interruptions? Do you have experience with data entry and multiple systems/screens? Do you have an active pharmacist license in your state of residence? Are you comfortable working independently in a productivity-based role? Do you bring a positive, engaged attitude to a team environment? We are hiring 50 Remote Clinical Pharmacist Advisors to support Medicare Part D members and providers in a fast-paced, high-volume, production-driven environment.
This role is ideal for pharmacists with prior authorization, managed care, or PBM experience who thrive in a structured, remote setting.
As a Clinical Pharmacist Advisor, you will review pharmacy benefit requests, make clinical determinations, and ensure compliance with CMS and Medicare guidelines while delivering best-in-class service.
Key Responsibilities Review and process prior authorizations, coverage determinations, and appeals Evaluate clinical documentation to support approval/denial decisions Ensure all cases meet Medicare Part D and CMS compliance standards Conduct provider outreach to obtain additional clinical information Document all decisions clearly and accurately in system workflows Manage high-volume queues while meeting productivity and quality metrics Apply clinical knowledge using drug compendia and established guidelines
Remote working/work at home options are available for this role.
Attorney Manager, Appeals & Rebuttals
A healthcare services organization is seeking an attorney-trained leader to manage provider and supplier enrollment appeals and rebuttals in a CMS-regulated Medicare environment. This is a law-degree-required management role responsible for overseeing appeal and rebuttal operations, guiding attorney-level written work, evaluating complex case records, and ensuring outcomes are timely, well-documented, and aligned with CMS guidance, contractual requirements, and internal procedures.
Candidates must have a J.D. and/or LL.M. from an ABA-accredited law school plus post-law-degree experience in administrative law or legal writing and research. Candidates without these qualifications will not be considered.
This role is a remote, permanent opportunity with occasional travel as needed for client-related meetings.
Applicants without the required law degree and post-law-degree legal experience will not be considered.
Compensation:
- Base salary: $100,000 to $130,000
- Bonus: 10% target bonus
Work Model:
- Remote
- Approved hiring states only: AL, FL, GA, MS, NC, SC, TX, or PA
- Preference for candidates near Northeast Florida or Mechanicsburg, PA, but this is not required
- Travel may be required based on client needs, though frequency is not yet defined
Position Overview:
The Attorney Manager, Appeals & Rebuttals, leads the day-to-day management of provider and supplier enrollment appeal and rebuttal operations in a structured Medicare environment. This role requires strong legal writing and research capability, sound regulatory judgment, disciplined execution, and the ability to manage complex administrative case workflows with consistency and precision.
This individual will supervise approximately 4 to 6 direct reports, maintain performance metrics for timeliness and quality, and partner closely with leadership, compliance, and legal stakeholders to support accurate, evidence-based case outcomes.
This is not a general healthcare operation, grievance-only, provider enrollment-only, paralegal, claims, revenue cycle, or compliance-only management role. It is a law-degree-required legal operations role for candidates with attorney-level writing, research, and administrative review experience.
Key Responsibilities:
Legal Operations, Leadership, and Compliance:
- Lead daily operations for provider and supplier enrollment appeals and rebuttals in a CMS-regulated environment
- Supervise and develop a small team responsible for appeal and rebuttal workflow, written case development, quality review, and administrative case processing
- Maintain team performance metrics tied to timeliness, quality, and compliance expectations
- Review complex appeal and rebuttal matters, assess facts and documentation, and guide consistent, well-supported outcomes aligned with CMS guidance and contractual requirements
- Ensure appeal and rebuttal narratives are supported by evidence, policy, and regulatory requirements
- Translate contractual and regulatory updates into operational workflows, written procedures, and team guidance
- Identify trends, risks, and process improvement opportunities and escalate issues as appropriate
- Support development and maintenance of documentation standards, administrative record quality, and defensible case handling practices
Appeals and Rebuttal Strategy:
- Lead strategy for appeal and rebuttal responses involving provider and supplier enrollment determinations
- Oversee the preparation and review of written narratives, case summaries, and supporting documentation
- Establish and maintain processes that promote timely, accurate, and compliant case handling
- Use workflow and performance data to identify recurring issues, improve quality, and strengthen operational consistency
- Incorporate findings into training, process updates, and policy refinement
Cross-Functional Collaboration:
- Serve as a subject matter resource and escalation point for internal leaders and partner teams
- Coordinate with internal and external legal stakeholders on documentation, case strategy, and administrative record development
- Support interactions with federal client stakeholders as needed regarding appealable and rebuttable determinations
- Collaborate across teams to improve upstream processes and reduce avoidable appeal volume
- Present trends, risks, and recommendations to senior leadership
Required Qualifications:
- J.D. and/or LL.M. from an ABA-accredited law school
- 3+ years of experience in administrative law or post-J.D./post-LL.M. legal writing and research
- 5+ years of supervisory or team leadership experience in legal writing, legal research, and/or administrative law
- Demonstrated ability to make objective decisions in a structured, high-compliance environment
- Experience analyzing workflows and performance data to improve operations and support regulatory compliance
- Strong verbal and written communication skills
- Ability to collaborate effectively across leadership, compliance, legal, and partner teams
- Ability to pass an additional Government ICT background investigation required for access to government systems
Preferred Qualifications:
- Supervisory or management experience in a Medicare production environment
- Experience supporting provider or supplier enrollment appeals, rebuttals, or related regulatory operations
- Experience working with CMS guidance, federal program requirements, and contractual service obligations
- Experience managing teams responsible for structured case review, written determinations, or administrative review workflows
Ideal Background:
- Prior experience leading structured appeals or rebuttal workflows in a highly regulated environment
- Strong legal writing and documentation discipline
- Experience reviewing complex records, applying policy and regulatory requirements, and guiding consistent outcomes
- Experience operating in environments where timeliness, quality, compliance, and audit readiness are critical
- Comfort working in a highly structured role with repetitive review responsibilities and clear performance expectations
Additional Information:
- Approximately 4 to 6 direct reports
- Role supports a function required by a federal client
- Travel may be needed for client-related meetings
- Start timing is flexible for the right candidate
Application:
Candidates with an ABA-accredited J.D. and/or LL.M., attorney-level legal writing and research experience, and management experience in administrative law or regulated healthcare appeals environments are encouraged to apply.
Applicants without the required law degree and post-law-degree legal experience will not be considered.
Manager of Enrollment & Reconciliation -
HealthCare Support is seeking a Manager of Enrollment & Reconciliation to support a Medicare Advantage Plan, delivering accessible, culturally attuned healthcare to the diverse populations it serves in Huntington Beach, CA!
Schedule
- Monday- Friday, 8am-5pm with 1-day onsite per week
Compensation
- $90,000 - $110K annually (depending on experience)
Daily Responsibilities
- Oversee and optimize all Medicare Advantage enrollment and reconciliation processes to ensure accuracy, compliance, and operational efficiency.
- Serves as the organization's expert on CMS rules, MARx transactions, eligibility policies, retroactive adjustments, and payment reconciliation requirements.
- Leads the team by setting priorities, guiding goals, and ensuring high?quality data capture and reporting.
- Manages MARx transaction processing, resolves rejections, reconciles CMS response files, and ensures alignment between internal systems and downstream partners like PBMs, claims, and finance.
- Identifies discrepancies, maintains governance around enrollment and payment accuracy, and ensures timely corrective actions.
Qualifications
- Bachelor's degree or equivalent combination of education and experience.
- 2 years of enrollment and reconciliation supervisory experience.
- 4 years of Medicare Enrollment experience at the health plan level.
- Experience Medicare Advantage Enrollment and Reconciliation rules and regulations, including CMS enrollment policy, MARx processing, payment reconciliation, and audit requirements.
- Expert-level knowledge of Medicare Advantage audit, compliance, enrollment, reconciliation, and regulatory reporting requirements
- Expert knowledge of Medicare Advantage enrollment transactions, reconciliation processes, and CMS enrollment policy.
- Advanced understanding of MARx transaction codes, CMS response files, and enrollment reconciliation workflows.
Interested in this opportunity?
Click Apply Now for immediate consideration, or reach out to our Recruiter, Melanie Williams with any questions:
- Call: (4
- Email:
- Schedule a Call: Support Staffing, LLC is an equal employment opportunity employer and will consider all qualified applicants without regard to race, color, religion, disability, sex, sexual orientation, gender identity, national origin, protected veteran status, or any other characteristic protected by applicable local, state, or federal law.
Details:
Job Title: API EM Quality Assurance Professional
Location: Indianapolis, IN
Duration: 12+ Months Contract (extendable)
Pay Range: $70 - $77 per hour on W2.
Qualifications:
At Client, we serve an extraordinary purpose. We make a difference for people around the globe by discovering, developing and delivering medicines that help them live longer, healthier, more active lives. Not only do we deliver breakthrough medications, but you also can count on us to develop creative solutions to support communities through philanthropy and volunteerism.
Join the energetic and growing Active Pharmaceutical Ingredient - External Manufacturing Organization (API-EM) that delivers a diverse portfolio of medicines essential to our patients around the world. The API EM Quality Assurance for Quality Control provides support to all QC activities at Contract Manufacturing organizations (CMs). The QA for QC position is essential for ensuring that all QC testing is in accordance with the validated methods and are compliant to cGMPs and regulatory commitments.
Basic Requirements:
• BS in a science-related field such as Pharmacy, Chemistry, Biological Sciences or related Life Sciences.
• 5+ years of GMP Quality Control Laboratory knowledge and/or experience in API or finished product manufacturing, QA or Engineering.
• Additional Preferences:
• Testing experience with Small Molecule
• Thorough technical understanding of quality systems and regulatory requirements relating to quality control laboratories
• Knowledge of pharmaceutical manufacturing operations.
• Demonstrated coaching and mentoring skills.
• Experience in root cause analysis.
• Demonstrated application of statistical skills.
• Demonstrated strong written and verbal communications skills.
• Strong attention to detail.
• Proficiency with computer system applications.
• Excellent interpersonal skills and networking skills.
• Ability to organize and prioritize multiple tasks.
• Ability to influence diverse groups and manage relationships.
Education Requirements:
• BS in a science-related field such as Pharmacy, Chemistry, Biological Sciences or related Life Sciences.
Other Information:
• Must complete required training for API EM Quality Assurance.
• No certifications required.
• Tasks require entering manufacturing and laboratory areas which require wearing appropriate PPE.
• Must be able to support 24 hour/day operations.
• Up to 20% travel US & OUS.
Responsibilities:
Key Objectives/Deliverables:
• Serve as a liaison between CMs and Client.
• Provide quality oversight of Quality control activities at CMs including being the initial point of contact for all quality-related issues with testing.
• Provide quality oversight of CM method validation or method transfer activities
• Escalate quality issues at CMs to Client's QA management.
• Assist in the establishment and revisions of Quality Agreements with affiliates and customers.
• Ensure compliance to Quality Agreements and Manufacturing Responsibilities Documents (MRDs).
• Coordinate and perform quality responsibilities of API shipments for stability testing. Provide quality oversight of API EM stability program.
• Participate in regulatory inspection preparations with CMs.
• Ensure that documented checks have been completed for the Certificates of Testing and Certificates of Environmental Monitoring (where applicable), and deviations, changes and batch documentation that demonstrates requirements have been met prior to batch release.
• Provide quality support of Quality Control with the focus on holistic review of key activities associated with or impacting the quality control testing including deviations, change controls and countermeasures.
• Assess the impact of analytical deviation investigations and changes and ensure that all appropriate records are documented and retrievable.
• Maintain awareness of external regulatory agency findings which individually or collectively reference the quality of the product.
• Review and approve documents including, but not limited to, analytical procedures, change control proposals, deviations, analytical equipment qualifications, analytical methods and computerized system validations.
• Participate in APR activities.
• Participate in projects to improve productivity.
• Participate in Joint Process (JPT) and Post Launch Optimization (PLOT) Teams.
$32.60 - $48.90 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.
Position Highlights:
* Position: Senior Coding Educator
* Location: Skokie, IL
* Full Time
* Hours: Monday-Friday, 8:00am-4:30pm
A Brief Overview:
The purpose of this job is to educate physicians, other qualified billing providers, and ancillary staff on their documentation for all specialties and review providers progress notes, as needed, to ensure coding/billing compliance in accordance with coding rules, third party payor guidelines, governmental regulations, and MG's Coding Compliance Program. The Senior Analyst will conduct face-to-face summary review sessions to report findings to the Practice Manager, Provider audited, and/or Senior Management of the MG. Through the audit/review process, this person will also conduct a report back to the provider and practice manager any income enhancing opportunities that might be uncovered in the investigation. The Senior Analyst, as a coding and billing expert, will assist all freestanding and provider-based outpatient departments with ICD-10, CPT-4, and HCPCS coding education and billing regulation interpretation. They will also assist in conducting department presentations.
What you will do:
* Analyzes progress notes, op reports, pathology reports, encounter forms, explanation of benefits, patient insurance information, and various other health information documents for pro-fee coding and billing accuracy.
* Assigns appropriate ICD-10, CPT, and HCPCS codes to medical record documentation under review by applying physician specialty coding rules, third party payor guidelines, and Medicare Local Medical Review Policies.
* Assists Manager/Director with providing information to the physician or medical specialty based on the Office of Inspector General's (OIG) and Centers for Medicare and Medicaid Services (CMS) risk areas. Reads the OIG's Semi-Annual reports and the OIG'S/CMS's Annual Workplan, in addition to notifications published on government websites.
* Performs physician and departmental documentation reviews based on industry standard coding and billing guidelines and payer policies to provide documentation and workflow improvement opportunities.
* Works with MG physicians or clinic personnel, HIRS, to interpret medical record documentation and/or documentation summary as necessary.
* Works with Customer Service and MG Operations to review and resolve escalated patient coding disputes.
* Works collaboratively with Billing, HIRS, overseeing provider/specialty and Denials Management Team to provide educational and/or income enhancing opportunities when issues are identified by those teams.
* Conducts educational sessions with Site Directors, Practice Managers, and providers on frequently seen coding errors in their site and assists with implementing changes to improve coding quality and minimize compliance risk.
* Provides feedback to Manager/ Director that identifies inefficient coding/operational processes.
* Assists with related special projects as assigned by Manager/ Director.
* Initiate and provide coding education to all MG billing providers, focusing on Evaluation and Management (E&M) documentation and billing requirements, as well as any specialty-specific coding guidelines.
* Works on special projects with the Hospital Billing Business Office and/or the Finance Department to perform reimbursement analysis functions as assigned by Manager/ Director.
* Submits ideas to Manager of Coding Quality & Auditing departmental newsletter based on coding/billing issues, coding help-line questions, or results of provider audits. May produce Monthly Newsletter if assigned.
* Participates in Coding and Business Operation Education in-services assigned by Manager
* Researches multi-specialty coding and billing questions received from the Coding Help-line/email for EHMG provider/staff and provides verbal or written response as appropriate. Maintains filing system of all questions received and answers provided to caller.
* Identifies trends or patterns of questionable coding and billing practices at Hospital Outpatient and Medical Group sites and reports issues to Manager.
* Reports compliance concerns to Manager or compliance hotline according to the Endeavor Healthcare Corporate Compliance Policy/Procedures.
* Develops physician coding tools such as ICD-10 and CPT-4 cheat sheets, coding grids, tip sheets and other educational material for multi-specialty providers to identify appropriate codes or modifiers reimbursed by payers for services performed.
* Assists in the creation of progress note templates per specialty utilizing the CMS documentation regulations or CPT Assistant guidelines as requested by physician's) or assigned by supervisor.
* Attends multi-specialty physician coding, billing, reimbursement seminars to maintain and increase coding, billing, reimbursement expertise/ knowledge.
* Maintains coding credential by obtaining the requiring continuing education credits per calendar year.
What you will need:
* Degree: Bachelor's degree in Health Information Management, Healthcare Administration, Nursing, or related field required; equivalent years of work experience in related field will be considered in lieu of degree
* Certification: RHIA, RHIT, CCS-P, CCS, or CPC required. CPMA preferred.
* Experience: 3-5 years of related experience in physician and hospital outpatient medical billing, reimbursement, physician audits, chart review, coding compliance, medical office or patient accounts. 1-2 years' experience working with Senior Physician Management a plus
Other required skills
* The ability to work independently, with little to no supervision
* Strong presentation and communication skills
* The ability to interpret and analyze medical record documentation, encounter forms, and lab reports, Explanation of Benefits, CMS claim forms, third party payor guidelines and government regulations.
* Aptitude for medical terminology, ICD-10, CPT-4, and HCPCS coding systems.
* Demonstrated expertise in multi-specialty evaluation & management (E/M) coding.
* Knowledge of research steps utilized to identify appropriate code selection or billing requirements.
* Proficiency in MS Office's suite of products, including Excel and PowerPoint, and the internet.
* Experience with Epic Billing Systems, including chart review, transaction inquiry, etc.
Benefits:
* Career Pathways to Promote Professional Growth and Development
* Various Medical, Dental, and Vision options
* Tuition Reimbursement
* Free Parking at designated locations
* Wellness Program Savings Plan
* Health Savings Account Options
* Retirement Options with Company Match
* Paid Time Off and Holiday Pay
* Community Involvement Opportunities
Endeavor Health is a fully integrated healthcare delivery system committed to providing access to quality, vibrant, community-connected care, serving an area of more than 4.2 million residents across six northeast Illinois counties. Our more than 25,000 team members and more than 6,000 physicians aim to deliver transformative patient experiences and expert care close to home across more than 300 ambulatory locations and eight acute care hospitals - Edward (Naperville), Elmhurst, Evanston, Glenbrook (Glenview), Highland Park, Northwest Community (Arlington Heights) Skokie and Swedish (Chicago) - all recognized as Magnet hospitals for nursing excellence. Located in Naperville, Linden Oaks Behavioral Health, provides for the mental health needs of area residents. For more information, visit you work for Endeavor Heal
