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#20-002586-0043
Supplemental Questionnaire

Last Name
First Name

 

***Please note that your answers on the supplemental questionnaire must correspond to the information provided on your application to receive credit. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval.***


1

Describe your knowledge of or experience working with Medicaid regulations.  Please include the name of employers, job titles, dates of employment, and hours worked per week. If you do not have this type of knowledge or experience, please write N/A.

 

 

2

Describe your knowledge of or experience working with Affordable Care Act regulations. Please include the name of employers, job titles, dates of employment, and hours worked per week.  If you do not have this type of knowledge or experience, please write N/A.  

3

Describe your knowledge of or experience working with consumer appeals hearings.  Please include the name of employers, job titles, dates of employment, and hours worked per week.  If you do not have this type of knowledge or experience, please write N/A.

4

Please describe the (4) years of required experience including employer name, dates employed, and job duties. Please specify experience in date order (current to past).


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