Molina Medicaid Solutions - DHHR

Bridging the Rivers ofChange TogetherWest Virginia MMIS Re-ProcurementSolicitation: MED13006ROLE RESPONSIBILITIES SKILL SETthe test plans Experience with Word, Excel and Adobe Reports quality review findings Detail oriented and organized Participates in the corrective action planactivities Excellent verbal and writtencommunication skills Participates in training facilitationRegisteredNurse(Sterilization/Hysterectomy)ReleaseManager Reviews forms or Physician CertificationStatements sent in for sterilization andhysterectomy for accuracy, completenessand meeting federal regulations andguidelines Enters authorizations into the system forapproval or denial, or return to provider forcorrections Reviews and processes claims for edit 225for emergency transportation. Reviewencompasses medical necessity andappropriate information provided Communicates with providers regardingconcerns about claims that have denieddue to the sterilizations, and hysterectomy,and other medical related questions Indexes prior authorizations and RTPletters into the PET system Reviews multiple ER visits per day, permember for medical necessity Provides assistance to customer service fordenials and guidelines followed formedical necessityDefines, documents, and follows thespecific process for each of the CRcategoriesMaintains and follows change managementplan documentEstablishes and follows prioritizationbusiness rules, project scope, andimplementation timelineMonitors change request (CR) tracking inRQMS and maintain updates to trackinginformationEstablishes and follows criteria for scopechanges, statements of work, costestimates, and invoicingReports to site leadership on CRperformance measurementsDevelops strong customer relationshipsbased on mutual respect and rigorousbusiness rulesWorks with site leadership and finance toensure timely invoicing of billable CRs andBachelor of Science in nursingActive license as a registered nurse inWest VirginiaOne year of Medicaid or health careexperienceKnowledge of professional nursingprinciples and techniques, medicalterminology, hospital routines andequipmentKnowledge of medications, includingnarcoticsTwo years experience in medicalknowledge related to appropriate patientcareThorough understanding of CPT/HCPCSand ICD-9 coding procedures andguidelinesExcellent verbal and writtencommunication skillsGeneral PC skills and Microsoft OutlookskillsBachelor Degree or equivalent experienceFive years experience in projectmanagement, software implementation, orsystem change managementStrong client-facing and relationship skillsrequired, including proven ability tomanage and disposition conflict resolutionDemonstrated ability to work effectivelyin a matrix organization and to get thingsdone without direct authority. Comfortableworking in a geographically disperseenvironmentDemonstrated written and verbalcommunication skills with customer,offsite support groups, and internaldepartment headsHealthcare claims processing experiencestrongly preferred14.4-36