Medical Assistance Specialist Resume Samples

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DV
D Von
Dorian
Von
9142 Gaetano Manors
Boston
MA
+1 (555) 756 0139
9142 Gaetano Manors
Boston
MA
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
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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1

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
2

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
3

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)
4

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?
5

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*
6

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
7

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
8

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
9

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
10

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
11

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
12

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."
13

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
14

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
15

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
16

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
17

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
18

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
19

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
20

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
21

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)