MCO Contract Control Audit Program Manager - (TMS) - 20068987

Highland County Joint Township•Ohio, IL

71d•Onsite

About The Position

The MCO Contract Compliance & Strategic Initiatives Lead plays a critical role in ensuring Managed Care Organizations (MCOs) meet all contractual, regulatory, and operational requirements. Under the direction of the Director of MCO Business Reporting, this position leads the development and oversight of contract controls, compliance monitoring, and strategic initiatives that support the integrity and performance of Ohio's MCO program.

Requirements

Completion of graduate core program in health care administration AND 12 months experience in medical policy development for medical provider or insurance company.
Or completion of undergraduate program core coursework in pre-medicine, allied medical field, nursing or related field of study AND 12 months practical experience in health care field AND 12 months experience in writing medical policies & procedures for medical provider or insurance company.
Or certified medical coder in current procedural terminology (CPT) hospital coding, or current ICD coding system AND 12 months experience in writing medical policies & procedures for medical provider or insurance company AND 12 months practical experience in health care field.
THE 12 MONTHS EXPERIENCE WRITING MEDICAL POLICIES & PROCEDURES IS REQUIRED FOR EACH SECTION FOR THE ABOVE MINIMUM QUALIFCATIONS. YOU MUST HAVE THIS IN ADDITION TO THE OTHER MINIMUM QUALIFICATIONS IN THE SECTION
Knowledge of medical/rehabilitation services; health care coverage & reimbursement techniques; health care administration; cost containment measures; statistical analysis; workers' compensation medical policies & insurance industry standards; supervisory principles/techniques.
Skill in operation of personal computer.
Ability to understand somewhat abstract field of study (i.e., health care); write & edit technical manuals & instructions; create complex reports using computer software; gather, collate & classify information about data, people or things.

Nice To Haves

The ideal candidate will be familiar with use of Microsoft Excel.
The candidate should also possess an ability to work both independently and to facilitate project teams and demonstrate a high level of critical thinking and analytical skills.

Responsibilities

Lead the monitoring and enforcement of MCO contract controls (e.g., Business Continuity Plans, cyber insurance, SOC1/SOC2 compliance).
Develop and implement policies and operational controls to ensure MCOs comply with contract terms and Ohio regulations.
Track and report MCO compliance status, timelines, and violations to the Director and Medical Services Chief.
Collaborate with the Compliance Performance and Monitoring (CPM) unit to address audit findings and ensure timely MCO responses.
Identify and document contract violations, providing evidence-based reports to leadership and legal teams.
Initiate and manage strategic projects (e.g., SOC2 training, AI-based continuity evaluations, compliance tracking tools).
Support the Director and Medical Services Chief in identifying and executing strategic initiatives.
Develop project plans, metrics, and presentation materials for internal governance and external stakeholders.
Represent the Medical Services Division in cross-divisional and external collaborations.
Write, implement and train on policy and procedures supporting and clarifying contract control requirements.
Design and deliver internal and external training on MCO contract control programs.
Serve as a representative on MCO Business Council subcommittees and workgroups.
Act as a spokesperson for the Director and Division leadership at meetings and events.
Assist in developing communication strategies for internal staff, stakeholders, and providers.
Provide guidance on division operations and staffing plans.
Conduct staff meetings and review incoming proposals with recommendations to leadership.
Serve as backup for managing MCO Business Unit communications and mailboxes.