authorizations, and insurance-related processes, including Medicaid and other payers. Identify, evaluate, and help prevent drug..., including prior authorization and Medicaid. Awareness of drug interactions and therapeutic considerations relevant to pharmacy...
& Payer Criteria Evaluation Review specialty drug access workflows across commercial, Medicare Part D, and Medicaid payer...
across commercial, Medicare, Medicaid, and managed care payers Evaluate AI-generated follow-up recommendations, claim status inquiry..., Medicaid, commercial payer, and managed care claim processing expectations Review accounts receivable KPIs such as days...
recommendations for accuracy and effectiveness Assess clinical and technical appeal content across commercial, Medicare, Medicaid..., and Medicaid payers Strong understanding of clinical and technical appeal processes, including peer-to-peer reviews and external...
involving Medicare, Medicaid, commercial payers, professional claims, facility claims, and payer-specific requirements Evaluate... Experience with Medicare, Medicaid, commercial payer billing rules, claim edits, and rejection workflows Proficiency...
involving commercial, Medicare Advantage, Medicaid, and other payer authorization requirements Assess authorization status... such as InterQual, MCG, or equivalent review standards Deep familiarity with commercial, Medicare Advantage, and Medicaid prior...
adjustment professionals experienced in HCC coding, Medicare Advantage risk adjustment, Medicaid managed care, ACA risk... Advantage, Medicaid managed care, and ACA risk adjustment programs Evaluate AI-generated HCC coding assignments and risk...
commercial, Medicare Advantage, and Medicaid managed care payer contracts Evaluate AI-generated underpayment alerts, payment...
workflows, Medicaid eligibility review, self-pay resolution, payment plan administration, and patient financial advocacy... involving charity care screening, financial assistance applications, Medicaid eligibility, and self-pay resolution Evaluate...
working with Medicare and Medicaid prescription benefits. Prior experience in a pharmacy benefit manager (PBM) environment...