Medicare Regulations Jobs

This full-time Clinical Investigator role, based in Iowa, focuses on identifying fraud, waste, and abuse within dental claims for Sun Life and DentaQuest. The position involves reviewing paid claims, interpreting dental radiographs, and conducting statistical analysis to detect utilization patterns outside expected norms. Key responsibilities include managing the full investigative lifecycle, collaborating with clients and law enforcement, and negotiating overpayment recoveries. The role appeals to licensed dental professionals seeking to apply clinical expertise in a hybrid work environment that balances office collaboration with remote flexibility. Candidates benefit from a supportive culture recognized as a top employer, offering comprehensive benefits, career growth opportunities, and a mission to improve oral health access.

This hybrid Clinical Intake Coordinator role supports the Home Health and Hospice team in Dedham, focusing on weekend operations. The position involves monitoring referrals through various systems, documenting patient interactions in the EMR, and utilizing nursing judgment to make immediate care decisions. Key responsibilities include coordinating clinician schedules, verifying managed care coverage, and providing guidance to field staff regarding patient needs. The role appeals to licensed nurses seeking a position that combines clinical expertise with administrative coordination in a collaborative environment. It offers a hybrid work arrangement and requires a Massachusetts LPN license along with experience in home care or hospice settings.

The Clinical Assessment Manager role within VNS Health involves conducting comprehensive clinical, environmental, and social assessments for New York members to establish individualized plans of care. Key responsibilities include performing face-to-face and telehealth evaluations, determining appropriate service levels in compliance with state and federal regulations, and collaborating with care teams to ensure cost-effective, high-quality community-based support. This position offers the appeal of working for a historic nonprofit organization dedicated to improving lives, featuring significant opportunities for professional growth, tuition reimbursement, and internal mobility. The role requires travel across upstate and downstate counties and is open to candidates with a New York nursing license and relevant clinical experience.

This full-time office role serves as an Admission Coordinator for a national hospice organization, focusing on facilitating compassionate care access for patients and families. The position manages the complete admissions workflow, acting as the primary contact for new referrals to ensure a seamless transition within a three-hour standard. Key responsibilities include coordinating with physicians and clinical teams, verifying insurance coverage, maintaining regulatory compliance, and supporting community outreach efforts. The role appeals to candidates seeking a mission-driven environment where kindness is celebrated and professional growth is supported through education assistance and career advancement opportunities. While primarily an office-based position, the role involves field communication and occasional after-hours support to meet patient needs.

The Clinical Assessment Manager role within VNS Health involves conducting comprehensive clinical, environmental, and social assessments for members to establish individualized plans of care that ensure safety within the community. Key responsibilities include performing face-to-face and telehealth evaluations, determining appropriate service plans, coordinating with providers and families, and ensuring strict compliance with state and federal regulations. This position offers significant appeal through a mission-driven culture at a leading nonprofit organization, extensive professional growth opportunities including tuition reimbursement, and a robust benefits package featuring generous paid time off and retirement matching. The role requires travel across New York State to conduct in-home assessments and supports a collaborative environment focused on high-quality, cost-effective healthcare.

The Reimbursement Supervisor role leads daily billing and revenue cycle operations within Bristol Hospice, partnering with clinical and operations teams to ensure accuracy and compliance. Key responsibilities include auditing admission and discharge documentation, verifying patient eligibility and payer coverage, managing authorization requests, and training staff on revenue cycle procedures. This position appeals to candidates seeking a leadership opportunity within a compassionate, family-centered organization that values integrity and excellence. The role offers a supportive culture with access to advanced training programs, comprehensive benefits including tuition reimbursement, and the chance to contribute to a mission dedicated to high-quality hospice care.

This full-time remote role serves as a Home Health Insurance Authorization Specialist within the CenterWell Home Health team, reporting to the Authorization Supervisor. The position focuses on ensuring accurate revenue recognition by auditing admission and discharge documentation, verifying patient eligibility, and managing authorization requests for Medicare, Medicaid, and commercial payers. Key responsibilities include resolving billing errors, communicating revenue issues to site leadership, and acting as a subject matter expert for reimbursement processes. The role offers a stable 40-hour workweek with flexible scheduling options and the opportunity to contribute to a mission-driven organization dedicated to personalized senior care. While primarily remote, occasional travel for training may be required, and the position includes a supportive environment with opportunities to mentor new associates.

This role serves as a Patient Care Coordinator within the Case Management team, focusing on optimizing patient outcomes through strategic care planning and utilization review. The position involves collaborating with physicians and multidisciplinary teams to develop comprehensive discharge plans, conduct daily utilization reviews, and ensure compliance with Medicare regulations and health plan benefits. Key responsibilities include monitoring care progression, identifying cost-effective protocols, and maintaining continuity of care across skilled nursing facilities and community services. The position offers the opportunity to work in a collaborative Labor/Management Partnership environment that values the nursing vision and continuous quality improvement. While the role is primarily administrative, it includes direct patient care duties to maintain clinical competency.

The Direct Care Worker role at 365 Health Services involves providing essential in-person support to patients in their homes across Eastern Pennsylvania. Key responsibilities include assisting with personal hygiene, mobility, and meal preparation while adhering to strict infection control and safety protocols. The position also requires accurate documentation of care provided and maintaining confidentiality in compliance with federal regulations. This opportunity is appealing due to the company's family-oriented culture, which emphasizes open communication and employee appreciation. The role offers flexible scheduling options with various shift lengths, allowing workers to choose hours that fit their lives, alongside comprehensive benefits including health, dental, and vision insurance.

The Direct Care Worker role at 365 Health Services involves providing essential in-person support to patients in their homes. Key responsibilities include assisting with personal hygiene, mobility, and meal preparation while adhering to strict infection control and safety protocols. The position also requires accurate documentation of care provided and maintaining confidentiality in compliance with federal regulations. This opportunity is appealing due to the company's family-oriented culture, which emphasizes open communication, professional development through high-level training, and a supportive environment with 24/7 management access. The role offers flexible scheduling options across various shifts and includes comprehensive benefits such as health, dental, and vision insurance.

This full-time or part-time Direct Care Worker role at 365 Health Services involves providing in-home personal care and support to patients in Eastern Pennsylvania. Key responsibilities include assisting with hygiene, mobility, and meal preparation while adhering to infection control and safety protocols. The position also requires accurate documentation of care provided and compliance with all federal and state regulations. The role is appealing due to a supportive family-oriented culture that emphasizes open communication and employee appreciation. Benefits include health, dental, and vision insurance, a 401k plan, and a flexible schedule allowing staff to choose their own hours across various shifts. The agency offers high-level training and 24/7 support from Client Service Managers to ensure a positive work environment.

This full-time Patient Account Associate II role is based in Broomfield, Colorado, within the revenue cycle team at Peaks Regional Office. The position focuses on resolving complex credit balance issues by researching payment details, validating adjustments, and interpreting payer contracts to ensure accurate account resolution. Key responsibilities include initiating refunds and recoupments, navigating claim portals, and mentoring new or existing associates. The role appeals to candidates seeking a supportive environment that prioritizes employee well-being through a comprehensive benefits package and a culture of wellness. While the position requires on-site presence at the office, it offers opportunities for professional growth in a collaborative healthcare setting.

The Sr. Director, Risk Adjustment Data & Analytics role is a senior leadership position within Alignment Health's data operations team, dedicated to advancing Medicare Risk Adjustment programs. The individual oversees the end-to-end data ecosystem, ensuring integrity and compliance while leading a multidisciplinary team of analysts and engineers. Key responsibilities include driving analytical insights for executive decision-making, maintaining rigorous data governance for audit readiness, and partnering with finance and clinical stakeholders to optimize revenue and care outcomes. This position appeals to candidates seeking to lead high-impact work in a mission-driven organization that prioritizes senior care. The role offers significant growth opportunities within a fast-growing company and is available in a remote work arrangement.

The Mount Sinai Health System seeks an Obstetrics and Gynecology System Medical Director to lead ambulatory services within its renowned New York facility. This role involves ensuring compliance with state prenatal regulations and Medicare teaching physician rules while aligning obstetrical care across the entire health system. The director will oversee performance improvement metrics, manage scope of practice for diverse providers, and partner with residency and fellowship programs to meet educational goals. The position offers the opportunity to work within a nationally ranked medical school environment featuring a fully integrated electronic health record and robust support staff. Candidates will benefit from a collaborative, team-oriented culture that integrates clinical care, research, and education, with flexible work arrangements supported by comprehensive professional development resources.

This hybrid role serves as a financial advocate for patients accessing complex specialty medications for serious conditions. The position involves investigating prescription benefits, securing insurance authorizations, and coordinating copay assistance or manufacturer programs to ensure patients can afford their treatments. Key responsibilities include navigating Medicare and Medicaid regulations, resolving insurance denials, and communicating sensitive financial information to patients and healthcare teams. The role appeals to those seeking to make a direct impact on patient care within a collaborative health system, offering opportunities to support vulnerable populations while developing expertise in pharmacy benefits and revenue cycle management.

The MDS Coordinator role at Voorhees Pediatric Facility involves managing the Minimum Data Set and Resident Assessment Instrument processes for a nationally recognized pediatric specialty care center. The position requires a licensed nurse to ensure accurate completion of assessments in compliance with federal and state regulations while supporting the Patient-Driven Payment Model. Key responsibilities include coordinating interdisciplinary care plans, analyzing data for quality improvement initiatives, and serving as the primary liaison for regulatory audits. This full-time, on-site position offers the opportunity to contribute to a mission-driven environment dedicated to advancing the life potential of medically fragile children. The role provides a collaborative culture with comprehensive benefits and professional growth within a leading healthcare organization.

The RN Admissions Coordinator - Utilization Management role operates within Carle Health's interdisciplinary team to oversee patient admissions and care transitions across Eureka and BroMenn facilities. Key responsibilities include conducting clinical assessments, coordinating with payers for preauthorization and concurrent reviews, and managing the discharge planning process to ensure appropriate levels of care. The position requires collaboration with physicians and families to optimize patient outcomes while maintaining compliance with Medicare and state regulations. This opportunity appeals to experienced nurses seeking a position that combines clinical expertise with strategic case management in a supportive environment. The role offers a hybrid work arrangement with on-site requirements at Eureka and occasional shifts at BroMenn, providing a chance to contribute to a Magnet-designated organization dedicated to community health and professional growth.

The RN Admissions Coordinator - Utilization Management role operates within Carle Health's interdisciplinary team to manage patient admissions and care transitions across Eureka and BroMenn facilities. Key responsibilities include conducting clinical assessments, coordinating with payers for preauthorization and concurrent reviews, and facilitating safe transitions from acute care to appropriate levels of care such as swing beds or home. The position requires collaboration with physicians and families to optimize patient outcomes while ensuring compliance with Medicare and state regulations. This opportunity appeals to nurses seeking a purpose-driven career in a Magnet-designated organization that values professional growth, community impact, and a supportive culture. The work arrangement involves on-site presence at Eureka with occasional afternoons at BroMenn based on census needs.

The Medical Social Worker role at Four Seasons in Henderson County provides psychosocial support to patients and families within the hospice and palliative care setting. Key responsibilities include conducting holistic assessments, developing care plans, coordinating discharge logistics, and serving as a liaison to community resources. The position offers the opportunity to work in diverse environments such as homes and facilities while contributing to a mission-driven organization recognized as a Best Place to Work. The role appeals to professionals seeking a supportive culture with comprehensive benefits, including tuition reimbursement and wellness programs, alongside a flexible schedule that accommodates full-time day shifts.

The Patient Access Representative I role serves as the frontline ambassador for Kaiser Permanente, welcoming patients into the healthcare system and initiating their clinical and financial records. Key responsibilities include conducting patient registration and insurance verification, collecting point-of-service payments, and ensuring strict compliance with federal regulations like HIPAA and EMTALA. The position requires close collaboration between financial and clinical teams to facilitate a smooth patient experience in high-volume settings such as emergency departments. This role appeals to individuals seeking a service-oriented career within a major health system, offering opportunities to develop strong organizational and problem-solving skills while supporting patient care. The position operates on a 12-hour shift schedule and may involve varied work environments including emergency and inpatient areas.

This part-time inpatient role involves Registered Nurses serving as Care Coordinators within a hospital setting to manage patient transitions and optimize care utilization. The position requires assessing patient needs, determining appropriate levels of care, and developing comprehensive discharge plans for both routine and complex cases. Key responsibilities include coordinating post-discharge services, collaborating with interdisciplinary teams to resolve barriers to safe transfers, and ensuring compliance with regulatory standards. The role appeals to nurses seeking a position that combines clinical expertise with care management, offering opportunities to advocate for patients and improve system efficiency. The schedule covers days with a 20-hour work week, including weekends and holidays, and requires licensure in Washington or Oregon.

The Manager, Care Management role operates within the Care Management department at Woman and Infants Hospital under the System Director. This position oversees daily departmental operations, provides leadership to achieve established goals, and facilitates collaboration among multidisciplinary teams, physicians, and external providers. Key responsibilities include managing acute care workflows, ensuring compliance with Medicare and Medicaid regulations, and utilizing clinical systems to optimize patient outcomes. The role is appealing for its opportunity to lead in a trusted health system known for medical research and innovative programs. Candidates will work in a collaborative environment that values ethical standards and professional growth, requiring a current RN license and relevant care management certification.

This full-time Registered Nurse role is based at the Residential Living Center within Holy Rosary Healthcare in Miles City, Montana. The position focuses on providing compassionate care to elders in a supportive, 47-bed unit with a collaborative interdisciplinary team. Key responsibilities include supervising nursing assistants, coordinating discharge activities, managing medication administration, and ensuring compliance with CMS and Medicare documentation standards. The role offers a flexible self-scheduling system for 12-hour day shifts and features a unique, family-like culture that includes resident engagement and on-site pet therapy. The environment emphasizes work-life balance and professional growth within a tight-knit team dedicated to enhancing resident well-being.

This full-time Registered Nurse role is based at the Residential Living Center within Holy Rosary Healthcare in Miles City, Montana. The position focuses on providing compassionate care to elders in a supportive, 47-bed unit. Key responsibilities include supervising nursing assistants, coordinating discharge activities, managing medication administration, and collaborating with an interdisciplinary team to develop individualized care plans. The role offers a flexible self-scheduling system with 12-hour day shifts and a collaborative culture that values resident input and team camaraderie. The environment is designed to feel like a second home, featuring unique elements like an on-site therapy dog and a strong focus on employee well-being and professional growth.

This per diem Nurse Practitioner role supports ComplexCare Solutions in Lancaster County, Nebraska, delivering high-value home and virtual health assessments for health plan members. The position focuses on evaluating current health status, identifying care gaps, and managing complex chronic conditions to keep patients out of the hospital. Key responsibilities include conducting comprehensive patient evaluations, documenting findings in compliance with CMS and HIPAA regulations, performing point-of-care testing, and collaborating with primary care providers to close care gaps. The role appeals to providers seeking autonomy in a remote clinical environment where they can spend up to an hour with each member to build meaningful relationships. The position offers flexible scheduling with a minimum monthly availability requirement and the opportunity to contribute to improved clinical outcomes for elderly and chronically ill populations.