Medical Assistance Specialist Resume Samples

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D Von

Dorian

Von

9142 Gaetano Manors

Boston

+1 (555) 756 0139

9142 Gaetano Manors

Boston

Phone

p +1 (555) 756 0139

Experience Experience

Los Angeles, CA

Medical Assistance Specialist

Los Angeles, CA

Koss-Hammes

Los Angeles, CA

Medical Assistance Specialist

Independently analyze records, cases, and situations and make timely, accurate decisions in providing expert consultation to customers via the client and provider toll-free lines, written correspondence, and email
Identifies and works in cooperation with other HCA staff to resolve ProviderOne and Siebel system issues, make photocopies, and prepare information to customers regarding medical assistance programs, services and billing policies
Ambulatory Surgical Center
Medical Vendor
Act as the MACSC liaison for coordinating all quality concerns, issues, and problems
Oversee the MACSC process for the distribution of complaint calls
Coordinate the other offices within Healthcare Authority to resolve the complex billing issues or billing questions

present

Chicago, IL

Medical Assistance Program Specialist

Chicago, IL

Gottlieb-Haley

present

Chicago, IL

Medical Assistance Program Specialist

present

Conducts data analysis of provider claim and managed care encounter data to identify aberrancies in health service utilization and/or payment
Provides subject matter expertise when vulnerabilities in the payment system or in program policy or rule are identified, and reports the vulnerabilities to prevent future improper payments
Generates reports that clearly communicate results, concerns, and status
Ensures that training program content is consistent with WACs, RCW, Medicaid program policies/procedures
Interfaces with training manager, training teams and unit supervisors/leads to understand and resolve any quality issues
Identify risks and assists in developing mitigation strategies. Mitigation strategy development includes but not limited to rewrite of training program content for consistency with WACS, RCW, Medicaid program policies/procedures
Answer and respond to high level call center calls and inquires as the subject matter expert

Education Education

Bachelor’s Degree in Independence

Johnson & Wales University

Bachelor’s Degree in Independence

Skills Skills

Demonstrated ability to adapt to change quickly
Demonstrated ability to prioritize effectively to meet workload demands
Demonstrated ability to multi-task and work in an environment with frequent interruptions
Ability to multitask and work in an environment with interruptions
Certified Professional Coder
Demonstrated experience processing claims in ProviderOne system
Demonstrated 10-key skills
Demonstrated time management skills
Independently review and process images for WA Apple Health; and
Review, accurately index, and process electronic images for returned mail utilizing the Kofax & WebAX imaging applications

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Medical Assistance Program Specialist Resume Examples & Samples

Directly responsible for using independent judgment and program subject matter expertise and knowledge to develop, write and oversee the First Steps ICM program, including ongoing policy, WAC, SPA, and Medicaid Billing Guide development
A Master's degree from an accredited college with a major study in public health, public administration, public policy, business administration, social work or closely related field and three years supervisory or consultative experience in health services, social service, Medicaid, or social security disability programs
Thorough understanding and experience in family support, home visiting and/or other early childhood or human service related field
Ability to understand, organize, and present information and data to various audiences
Ability to organize, prioritize, and complete work within required timelines
Demonstrated strong written and oral communication skills
Ability to respond quickly to special requests
Strong facilitation skills including the ability to communicate effectively and work collaboratively with diverse populations including agency personnel, stakeholders, and partners
Experience writing Medicaid State Plan Amendments, Washington Administrative Code, Medicaid Billing Guides, and technical reports
Experience reviewing and analyzing regulatory requirements

Medical Assistance Specialist Resume Examples & Samples

One (1) year of experience as a Medical Assistance Specialist 2 or equivalent
Knowledge and understanding of various health care coding structures (CPT, HCPCS, ICD-9, ICD-10 etc.)
Intermediate-level proficiency with Microsoft Excel, Word and Outlook
Demonstrated ability to adapt to change quickly
Demonstrated time management skills
Demonstrated ability to prioritize effectively to meet workload demands
Demonstrated 10-key skills
Minimum of one (1) year of experience processing, adjusting, investigating, and/or adjudicating of various types of health insurance premiums/claims
Certified Professional Coder
Demonstrated experience processing claims in ProviderOne system

Medical Assistance Specialist Resume Examples & Samples

Researching and analyzing complex rules, regulations, or policies
Utilizing research and analysis to make determinations, solve problems, or complete work
Providing direct customer service either in person or via the telephone
Mandatory work schedule of 8:30AM – 5:30PM
Computer skills, knowledge of ACES, ProviderOne, Siebel, and knowledge of Medicaid programs
Ability to consistently provide excellent customer service during a full shift of continuous phone calls within a toll free customer service center
Ability to manage information arising out of conflicting rules and procedures that are established by other sections over which you have no control (i.e. a program withdraws a benefit which results in phone inquiries to MACSC form affected providers)
Ability to manage stress arising out of diverse conflicts and the demands of customers to provide the correct resolution of issues within a short period of time
Ability to counsel and placate customers' expectations when they are different from the policy and regulations under WAC
Current resume (Not a substitute for the completed application)

Medical Assistance Specialist Resume Examples & Samples

A Bachelor's degree and one year of experience providing direct client services or counseling of customers in the areas of health insurance, disability, or other related health benefits; public assistance eligibility determination; health insurance premiums/claims processing, adjusting, and investigation; or other medical premiums/claims related experience
One year as a Medical assistance Specialist 2
Three years of experience providing direct client services or counseling of customers in the areas of health insurance, disability or other related health benefits; public assistance eligibility determination; health insurance premiums/claims processing
None of the above
2. Do you have experience with ProviderOne or any other Medicaid Management Information System (MMIS)?
3.If you answered yes to the question above, please explain where and when you obtained this experience. Include employer, job title, and duration. If you answered no, please indicate "N/A" in the space below
4.You must pass a Washington State Patrol WATCH criminal background check administered by the Health Care Authority. Are you willing to accept this as a condition of employment?

Medical Assistance Program Specialist Resume Examples & Samples

Assesses billing or clinical practice aberrancies for both Fee-for service and Managed Care applicable to individual target provider
Analyzes claim payment or managed care encounter history to identify provider specific utilization aberrancies
Directly responsible for researching an analyzing healthcare, financial, and administrative records to determine compliance with agency and state rules, regulations and policies
Interprets complex information from a large volume of regulatory, advisory, and claims payment system documents
Documents findings to support conclusions and recommendations
Formulates and implements corrective actions and/or administrative sanctions, including identification and referral of improper payments
Requests healthcare records for review, prepares reports, and referrals as necessary to appropriate division, office, unit or agency
Monitors provider compliance with educational outreach and corrective actions
Records, develops, maintains, and tracks progression of case in the appropriate tracking system
Assists in development of tools to sort and analyze and report complex data
Represents the Agency as needed when findings are disputed or appealed
A cover letter
Persons under final consideration for initial appointment with HCA are subject to a background check*

Medical Assistance Specialist Resume Examples & Samples

Experience performing conflict resolution with customers
Knowledge of Medicaid programs and eligibility
Experience utilizing Microsoft Office programs such as Outlook, Word, and SharePoint

Medical Assistance Program Specialist Resume Examples & Samples

Directly responsible for ongoing program and policy development activities, provider monitoring, training and technical assistance activities, and program monitoring to ensure compliance with federal, state, and HCA regulation for assigned MAC programs
Provide professional and technical subject matter expertise and guidance for developing, writing, implementing, and overseeing policies and procedures having statewide impact on assigned MAC programs for Medicaid outreach to families and subsequent linkage to healthcare providers through public agencies
Directly responsible for independent judgment and program subject matter expertise for contract planning, negotiation, development, writing of special terms and conditions, documenting contract records, implementation, review and approval of contractor invoices, contract administration, oversight, monitoring and ongoing evaluation for assigned MAC program contracts and Department of Enterprise Services (DES) work order contracts and Request For Proposals (RFPs) related to assigned MAC programs
Represent HCA and the state in negotiations with state and federal partners on major, substantive, and innovative MAC program methods and related federal law impacting HCA
Represent HCA at community forums and meetings, and prepare, present, recommend and report to external stakeholders which may include CMS, the Governor's office, the Legislature, local and state agencies, constituents, the private sector and public contractor community, consultants, community organizations and persons and families, benefiting from Medicaid outreach and provider linkage efforts provided through assigned MAC programs
Provide related MAC program and time study system training to external stakeholders, internal managers and work units as needed
Plan, design, develop, write, schedule, test, implement, evaluate and improve program policy and procedures providing for assigned MAC program business requirements and operational processes
Perform as a consultant program expert and provide subject matter expertise to assist with program administration and oversight, program development and management, contract development and monitoring, and invoice/claims review and payment for all of HCA's MAC programs and related time study and claiming processes
Communicate and work effectively with a broad range of program and fiscal managers and staff, contractors, and their agents, legislators and legislative staff, CMS, and other stakeholders
Coordinate and track multiple, diverse activities and work independently with limited supervision
Make clear, understandable written, graphic and verbal directions
Make presentations consisting of cost/benefit, process improvement and similar analyzes and policy recommendations
Envision and develop timely program plans and monitoring of results
Write clear and concise reports
Flexibility to navigate change and adapt priorities
Ability to present complex material to diverse stakeholder groups

Medical Assistance Program Specialist Resume Examples & Samples

Must have working knowledge of ProviderOne
Must have ability to evaluate and accurately report cost savings
Must have ability to establish and manage enhanced standards and processes for quality improvement
Must be able to analyze and present the data generated for the stakeholders in a way that is both clear and meaningful
Must be able to maintain attention to detail while at the same time multi-tasking in a fast paced work environment
Must be able to foster solid working relationships across all levels of the organization and with external stakeholders

Medical Assistance Specialist Resume Examples & Samples

Independently analyze applications, determine initial and/or ongoing eligibility and authorize benefits for Medicaid programs administered by the Medical Eligibility Determination Services (MEDS) office
Independently determine initial and/or ongoing eligibility for Health Care Authority Medicaid Title XIX, CHIP Title XXI, and other Medicaid and state funded medical assistance programs administered by the MEDS office
Apply complex federal and state eligibility regulations published in WAC and RCW to specific household circumstances resulting in accurate eligibility decisions
Use and manage multiple interdependent electronic systems including but not limited to the Automated Client Eligibility System (ACES), HealthPlanFinder, Provider One, Barcode, WebAx, Audit Plus, SharePoint, Microsoft Office, SOLQ, Document Management System (DMS) and Employment Security Department (ESD)
Analyze research and resolve complex eligibility issues applying proper rules and procedures with a high degree of independence. Work on programs such as but not limited to
Post Eligibility Reviews (PER's)
Alien Emergency Medical (AEM)
Citizenship/ Immigration
Retro's
Spenddowns
Appeals
Chip Acuity
Pends
Take Charge
Complex Error Codes

Medical Assistance Specialist Resume Examples & Samples

One (1) year of experience as a Medical Assistance Specialist 1 or equivalent
Intermediate-level proficiency with Microsoft Excel, Microsoft Word
Experience using ProviderOne, HealthPlanFinder, Washington Connection, and/or SharePoint
Ability to multitask and work in an environment with interruptions

Medical Assistance Program Specialist Resume Examples & Samples

Driving down the cost and improving the turn-around time for execution of the QA process. This position would be accountable for QA department process definition and management, define/manage QA operations/manage QA
Accountable to develop a management system that will be used for day-to-day management of the QA function, as well as provide information that would be needed to drive continuous improvement in all the functions
Accountable for review of Requirements and Specifications, of training program. Provides input to training manager, trainers
Generates reports that clearly communicate results, concerns, and status
Accountable for managing/monitoring staff performance in accordance with training program guidelines
Ensures that training program content is consistent with WACs, RCW, Medicaid program policies/procedures
Accountable to define and manage all QA processes; emphasis is on optimization and consistency. Period calibration session may occur to re-establish baselines especially for individual training plan assistance
Interfaces with training manager, training teams and unit supervisors/leads to understand and resolve any quality issues
Identify risks and assists in developing mitigation strategies. Mitigation strategy development includes but not limited to rewrite of training program content for consistency with WACS, RCW, Medicaid program policies/procedures
QC observation of call taker looks for presentation skills and content knowledge deficiency which may lead to call taker providing information in violation of WAC, RCW, Medicaid program policies/procedures
Proactively works with the training and operation managers to forecast Quality control needs and skills to establish manage and optimize a workforce that supports current and longer term strategic objectives of the organization
Ensure clear metrics are defined, implemented and track to measure performance, skills, throughput and quality of work performed by the section as a whole and personnel staff. This helps identify modifications that may be need in training program focus in support of organization's strategic objectives
Minimum of three years call center experience, preferably MACSC
Minimum one year of experience within the last 24 months in MACSC as a Medical Assistance Specialist 5 Supervisor OR minimum one year of experience within the last 24 months in MACSC as a MAS-3 where the primary duties (75%) were to provide direct services on toll-free lines assisting clients with access to appropriate medical services and enrolling them in managed care plans, and resolving provider billing issues ensuring appropriate reimbursement for services provided
Demonstrates familiarity with Quality Management and/or training principles and techniques
Excellent organization and time management skills
Solid oral and written communication skills
Excellent problem solving skills, along with the ability to recognize potential trends and implications
Demonstrates proficiency in planning, design, and project management skills
Demonstrates proficiency in Outlook, Word, and Excel

Medical Assistance Specialist Resume Examples & Samples

Independently determine initial and/or ongoing eligibility for Health Care Authority Medicaid Title XIX, CHIP Title XXI, and other Medicaid and state funded medical assistance programs administered by the MEDS office,
Use and manage multiple interdependent electronic systems including but not limited to the Automated Client Eligibility System (ACES), HealthPlanFinder, ProviderOne, Audit Plus, Microsoft Office, SOLQ, Document Management System (DMS) and Employment Security Department (ESD)
Analyze, research and resolve complex eligibility issues applying proper rules and procedures with a high degree of independence
Conduct interviews over the telephone, in person, and/or through written correspondence with clients, providers and/or third parties to obtain information for required documentation and verification to support program eligibility. Establish effective working relationships with clients and their advocates and manage difficult interactions with tact and diplomacy
Work with individual Take Charge providers to answer inquiries and resolve issues related to eligibility for the Take Charge Family Planning program
Maintain a high level of local customer service that supports and extends the presence of the agency in the community."

Medical Assistance Specialist Resume Examples & Samples

Provide eligibility support and clarification to MAS level staff determining initial eligibility and/or ongoing medical eligibility. As an eligibility expert, interprets policy and regulations, analyzes workflow and automated systems problems. Devises and implements new and revised procedures and monitors ongoing systems operations in the broader aspects of MEDS related system activities
Provide eligibility training for new staff to determine initial and/or ongoing eligibility for Health Care Authority medical programs. Provide system training, interviewing and workload management for new staff
Apply complex federal and state eligibility regulations published in WAC and RCW to specific household circumstances resulting in accurate initial and ongoing eligibility decisions. Requires mastery of EAZ manual, ACES manual and other materials published by the agency related to medical program eligibility
Develop eligibility and system training for new and seasoned staff based on program changes and changes to eligibility. Develop and provide training on identified performance gaps. Develop training based on new/changed policies and procedures for all staff
Use and manage multiple inter-dependent electronic systems including but not limited to the Automated Client Eligibility System (ACES), Provider One, Audit Plus, Microsoft Office, SOLQ, Document Management System (DMS), SEMS, TALX, DOH, and the Employment Security Department (ESD),
Conduct internal program audits of new and experienced staff, identifying error trends and performance issues

Medical Assistance Specialist Resume Examples & Samples

Achieve PEB Division Customer Service Level (CSL) of 80% of calls answered in 60 seconds consistently for year-end average. Note: This measure is impacted by the number of trained staff available in PEB Division PCS. In addition, the CSL will be re-evaluated during this review period to align with the Result HCA goals for calls answered
Achieve TAT goals for correspondence and appeals for year-end average (<30 days) and documents (<5 days)
Achieve a lobby wait time of 5 minutes or less consistently for year-end average
Maintain accuracy results for PEB Division PCS managed accounts at 95% or higher consistently for year-end average
Coordinate personnel issues for recruitments, selections and appointments. Screen, interview, recommend and hire prospective candidates for employment
Create and maintains staff Position Description Form (PDF) within unit. Align staff positions and duties within their job classifications
Conduct timely and accurate employee performance evaluations per agency standards. Document staff performance in supervisor file during evaluation period
Set clear expectations, work plan goals and assignments. Mentor and provide leadership for staff growth. Monitor staff work to ensure adherence to daily schedule: ensure that members' calls are answered timely, accurately and courteously, walk-in members receive timely and accurate services, documents are processed within established turnaround guidelines and account information is accurate and consistent with WACs, rules, PEBB Program policies and procedures
Conduct bi-monthly team staff meetings
Conduct monthly 1x1 meetings with staff to review and discuss their performance measures and customer service work and more frequently with those who do not meet expectations

Medical Assistance Program Specialist Resume Examples & Samples

Participate in contract development, amendments, negotiations and implementation
Participate in program and policy development and implementation
Develop program manuals, instruction and guidance
Evaluate utilization and formulate recommendations and long term strategies
Participate in CBA activities including bargaining and grievance processes
Conduct research to identify best practices and areas for improvement
Provide technical assistance to address/resolve concerns or issues
Develop communications including briefing papers, decision packages, governor alerts, legislative bill language, and other official correspondence
Facilitate meetings/workgroups
Plan, develop, and implement performance-based contract monitoring procedures including monitoring tools, corrective action plans, and other documentation
Conduct monitoring activities including claim review, desk/site reviews, utilization and claiming data reports, or other methods of monitoring Monitor and track administrative expenditures to ensure payments do not exceed the program budget
Develop utilization reports including CBA required reports
Conduct claiming and utilization audits
Monitor Contractor's website for accurate and complete requestor information
Experience in delivering training and facilitating groups
Ability to work cooperatively and as part of a team
Ability to self-direct and work with diverse cultures
Strong computer skills including MS office (Word, Excel, PowerPoint, SharePoint etc.)
Ability to work in a highly politically charged working environment
Ability to quickly adapt to a rapidly changing work environment
Two years of contract management experience
Ability for occasional overnight travel across the state to attend work-related meetings, trainings, and monitoring
Ability to work independently with little supervisory direction

Medical Assistance Specialist Resume Examples & Samples

One (1) year of experience as a Medical Assistance Specialist 2
Demonstrated ability to multi-task and work in an environment with frequent interruptions
One (1) year of experience as a Medical Assistance Specialist 1

Medical Assistance Specialist Resume Examples & Samples

Ensure only qualified providers are enrolled with HCA and provider eligibility requirements are met for each specialty
Ensure Federal, State and other applicable regulations and procedures and policies are followed; and
Ensure applications and related work is approved in a timely manner
For each provider enrollment application

Medical Assistance Specialist Resume Examples & Samples

Serves as designated Team Lead worker and subject matter expert for all call center line staff - assisting with the resolution of complex client and provider concerns
Provides specialist assistance to call center staff as well as Apple Health contracted providers, with concerns related to Apple Health client benefit service packages, access to care issues, and provider billing, policy and payment concerns
Independently analyzes client eligibility, and makes timely, accurate decisions to assist clients in determining services they qualify for based on their eligibility for Apple Health
Counsels and advises clients on scope of care and clients' rights and responsibilities
Resolves questions, complaints and problems about eligibility, accessibility to services, enrollment and other insurance coverage
Counsels clients on Medical Assistance policies, procedures and health benefits as outlined in RCW, WAC, and HCA policies and procedures
Uses information, questions, and complaints from clients and client advocates to enhance program policy and procedures
Provides appropriate consultation to medical providers in order to expedite the reimbursement for title XIX claims submitted to the Health Care Authority for payment
Evaluates medical claims for correct adjudication, counsels providers on appropriate billing procedures
Researches and identifies workflow and system problems, recommends and implements new/revised procedures
Provides second level training for newly released staff trained on client and/or provider Medical Assistance Center skills, processes and procedures
Establishes and maintains an effective relationship with Apple Health Medicaid program and policy management to assist providers in solving complex billing concerns
Attends HCA Program and Policy Meetings as needed
Escalates client and provider concerns to HCA technical and Policy management as needed to resolve caller concerns
Managed the Lead Queue bucket and take over Service Requests posted by staff on a daily basis and respond by email to clients and providers on complex issues
Assists Supervisors and other Call Center Managers with responding to Client and Provider related inquiries as delegated by the Supervisor or Manager

Medical Assistance Specialist Resume Examples & Samples

Excellent knowledge of PEBB Program information sources, including WACs, policies, and procedures
Superior communication, customer service, time management, and interpersonal skills. Ability to achieve results and stay calm under stressful circumstances
Experience using the Pay1 system, with databases, and software programs. Excellent mathematical skills
Ability to handle competing priorities and multiple deadlines
Ability to have difficult conversations with MAS3, peers, or other staff diplomatically

Medical Assistance Program Specialist Resume Examples & Samples

A Bachelor's degree in business or public administration or a relevant field
Experience with ProviderOne system required
Expert personal computer/office machine skills required
Skilled in Microsoft Excel
Intermediate skills required for Microsoft Access, Word, and PowerPoint
Skilled in analytical disciplines including logic, research, statistics, and data analysis
Knowledge of medical terminology and provider specialties
Knowledge of Medicaid and Medicare payment policies
Knowledge of HCA's Physician-Related Services Billing Instructions and relevant WACs, in addition to familiarity with reimbursement methodologies for services provided by physicians and other healthcare professionals
Knowledge of federal Medicaid and Medicare statute (USC) codes (CFR), Medicaid State Plan, state laws (RCW), and regulations (WAC) that pertain to reimbursement and qualifications for Medicaid reimbursement
Knowledge of federal FQHC and RHC reimbursement systems and health economics, and a well-developed sense of social and fiscal considerations essential to crafting good public policy

Medical Assistance Specialist Resume Examples & Samples

Determines prior authorization of Dental and Orthodontic services
Track program activity
Process Improvement and Program Enhancements
Experience and knowledge in the Provider One system (MMIS)
Knowledge of Dental/Medical Terminology and Washington Administrative Codes (WAC) related to prior authorization, Agency administered programs, and the Health Care Authority (HCA) Medicaid Provider Guides
Ability to use multiple software applications (e.g. Microsoft Word, Excel, Access, and Outlook)

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