Director of Managed Care

State of South Carolina•Lexington County, SC

3d•Onsite

About The Position

The Director of Managed Care provides strategic and operational leadership for BHDD’s Medicaid and managed care activities. The position serves as Finance’s principal subject matter expert and primary liaison with the South Carolina Department of Health and Human Services (SCDHHS) on Medicaid matters affecting BHDD. It maintains a comprehensive understanding of Medicaid policy, reimbursement, program requirements, and operational processes, and acts as BHDD’s primary Finance liaison with Medicaid managed care organizations and other significant third-party payers. The Director ensures the agency effectively manages the intersection of Medicaid policy, managed care requirements, reimbursement, enrollment, and revenue cycle operations. The role identifies and resolves systemic payer issues, evaluates Medicaid and MCO changes for financial and operational impact, and coordinates responses across Finance, Revenue Cycle, clinical operations, information technology, legal, compliance, and other agency functions. It also supervises staff assigned to managed care and enrollment functions and performs related duties and strategic assignments as directed by the Controller or Chief Financial Officer. The position is located at the SC Department of Behavioral Health and Developmental Disabilities (BHDD), Central Office, 400 Otarre Parkway, Cayce, SC 29033.

Requirements

Bachelor’s degree in finance, accounting, healthcare administration, business administration, public administration, or a related field, and significant professional experience in Medicaid, managed care, payer relations, healthcare finance, reimbursement, revenue cycle, or a related field.
Relevant experience may substitute for specific educational requirements consistent with State of South Carolina classification requirements.
Extensive knowledge of Medicaid reimbursement, policy, managed care, and healthcare payer operations.
Ability to develop expert-level knowledge of South Carolina Medicaid programs and requirements applicable to BHDD.
Strong knowledge of managed care contracting, reimbursement methodologies, provider enrollment, claims operations, and revenue cycle processes.
Ability to interpret complex Medicaid regulations, policies, manuals, contracts, reimbursement methodologies, and payer requirements.
Strong financial and analytical skills, including the ability to quantify the impact of reimbursement and policy changes.
Ability to identify systemic operational and financial issues and lead cross-functional resolution.
Ability to establish effective relationships with Medicaid agencies, MCOs, executive leadership, and other external stakeholders.
Strong negotiation, communication, presentation, and relationship-management skills.
Ability to translate complex Medicaid and payer matters into clear financial and operational implications for executive leadership.
Ability to lead complex initiatives across multiple organizational functions without direct supervisory authority over all participants.
Post-hire, have knowledge of an agency’s mission, programs, and objectives; management principles; the agency’s organizational structure and work processes; and the people who manage the work.
Post-hire, be able to interpret and apply rules and regulations, manage work and provide guidance to employees, make presentations, and prepare reports.

Nice To Haves

Master’s degree in business, healthcare administration, public administration, finance, or a related field.
Significant experience with Medicaid, preferably South Carolina Medicaid.
Experience working directly with a state Medicaid agency or Medicaid managed care organizations.
Experience within behavioral health, developmental disabilities, hospital, or large healthcare delivery systems.
Experience with Medicaid reimbursement methodologies, payer contracting, provider enrollment, and revenue cycle operations.
Prior supervisory or leadership experience.

Responsibilities

Develop and maintain subject matter expertise regarding South Carolina Medicaid programs applicable to BHDD services, including reimbursement methodologies, covered services, eligibility and authorization requirements, billing rules, provider requirements, and program changes.
Monitor Medicaid policy, State Plan amendments, provider bulletins, manuals, reimbursement changes, waivers, managed care requirements, and other developments affecting BHDD.
Evaluate the financial and operational impact of Medicaid changes and coordinate implementation across affected BHDD functions.
Serve as the primary Finance liaison between BHDD and SCDHHS on Medicaid reimbursement, policy, billing, enrollment, managed care, and related financial matters.
Serve as the primary Finance liaison with Medicaid managed care organizations and other significant third-party payers.
Develop and maintain productive working relationships with SCDHHS, MCO leadership, payer representatives, and other external stakeholders.
Lead resolution of significant or systemic Medicaid and MCO issues involving reimbursement, claims, denials, authorization, enrollment, eligibility, payment, or payer policy.
Represent Finance on internal and external workgroups involving Medicaid, managed care, reimbursement, and payer operations.
Coordinate managed care contracting, contract implementation, amendments, reimbursement changes, and operational requirements in partnership with Legal and agency leadership.
Ensure MCO contract requirements and reimbursement arrangements are consistent with applicable Medicaid policy and understood by affected BHDD functions.
Monitor payer performance and identify trends affecting reimbursement, accounts receivable, denials, claims processing, and cash collections.
Evaluate reimbursement methodologies and identify opportunities to improve revenue realization, reimbursement accuracy, and financial performance.
Develop financial models and analyses related to Medicaid reimbursement, managed care arrangements, payer changes, and proposed policy changes.
Maintain executive visibility into enrollment status, payer participation, outstanding applications, revalidations, and enrollment-related financial risks.
Develop dashboards and executive-level reporting regarding Medicaid and managed care performance, significant payer issues, enrollment status, financial exposure, and emerging risks.
Advise the Controller, Chief Financial Officer, and executive leadership regarding significant Medicaid and managed care developments and their financial implications.
Coordinate organizational responses to Medicaid and managed care audits, reviews, inquiries, and data requests involving Finance.
Coordinate cross-functional projects involving Finance, clinical operations, information technology, compliance, legal, and external payers.
Establish standardized processes, controls, documentation, and accountability for managed care activities across BHDD.
Supervise staff assigned to managed care and enrollment functions.
Perform other related duties and strategic assignments as directed by the Controller or Chief Financial Officer.

Benefits

Health insurance for employees, spouse, and children
Dental insurance for employees, spouse, and children
Vision insurance for employees, spouse, and children
Long-term disability insurance
Life insurance for employees, spouse, and children
15 days of annual (vacation) leave per year
15 days of sick leave per year
13 paid holidays
Paid parental leave
South Carolina Deferred Compensation Program
Retirement benefit choices through the State Retirement Plan (SCRS) or State Optional Retirement Program (State ORP)