Provider Certification Specialist (Org Wide)

Lakeland Care Incorporated•Town of Ledgeview, WI

About The Position

The Provider Certification Specialist provides initial, annual, and additional recertification services for certified Adult Family Homes (AFHs) in Lakeland Care, Inc.’s provider network. Under the supervision of the Provider Relations Residential Supervisor, the role helps build strong partnerships with new and existing AFH providers, community agencies, and community representatives to support an adequate provider network. The specialist keeps provider documentation current, conducts onsite visits, monitors quality-related data, and checks providers’ adherence to contract requirements. The position has a multi-county focus and works closely with both Provider Relations Managers. It ensures contracted certified AFHs meet contractual certification requirements, Wisconsin standards for certified 1–2 bed Adult Family Homes, and home and community-based services (HCBS) setting requirements. The specialist performs certification and recertification reviews, documents findings and actions, identifies and escalates concerns, supports provider training, and collaborates with LCI staff, providers, and other certification agencies.

Requirements

Bachelor’s degree in a human service or business-related field, or an equivalent combination of formal education and experience, including relevant knowledge, skills, and abilities.
Excellent verbal and strong written communication skills.
Outstanding organizational skills and the ability to manage multiple responsibilities.
Current driver’s license, acceptable driving record, and proof of adequate insurance.

Nice To Haves

One year of experience completing AFH certifications or working directly with contracted providers.
One year of experience working with LCI’s target populations.
Knowledge of the service provider industry, subcontracting, licensing, regulatory systems, and provider-network contracting in a managed care model.
Experience, training, skills, or aptitude collaborating with potential or current AFH providers.
Experience, training, skills, or aptitude reading and understanding contract language, standards, and requirements.
Experience, training, skills, or aptitude analyzing and interpreting data.
Experience, training, skills, or aptitude providing education and training to improve outcomes.
Comfort addressing groups.

Responsibilities

Collaborate in developing provider certification and contracting standards and consistent processes for ongoing compliance with DHS contracting standards.
Conduct certification and recertification activities objectively and consistently using documented evidence, applicable DHS standards, LCI requirements, and established procedures.
Maintain complete, accurate, and timely documentation related to certification status, deficiencies, corrective actions, conditions of approval, exceptions, and other certification actions.
Determine compliance with administrative, operational, physical environment, life-safety, quality-of-care, and quality-of-life requirements; identify and communicate issues and concerns.
Review monthly data to identify trends in network adequacy and capacity and recommend action plans to address gaps.
Identify, document, and appropriately escalate potential noncompliance, health and safety concerns, and situations requiring further review, inspection, corrective action, or other certification action.
Conduct required onsite certification and recertification reviews, validate applications and supporting documents, observe the home and environment, and engage appropriate individuals to determine compliance.
Ensure certified AFH providers adhere to LCI contracts, Wisconsin Medicaid Standards for Certified 1–2 Bed Adult Family Homes, and HCBS setting requirements.
Collaborate with other certification agencies on quality concerns that may jeopardize residents’ health and safety.
Ensure providers have adequate training and access to training resources.
When requested, document AFH exceptions in writing and report exception requests and granted exceptions to DHS quarterly.
Communicate effectively with LCI contracted providers and other LCI departments to support organizational practices.
Provide training opportunities or educational resources on certification and recertification requirements to 1–2 bed AFHs and LCI staff, in collaboration with the Contracting and Development Manager.
Attend professional meetings, including community provider association meetings, as assigned, and train or update Provider Relations team members as appropriate.
Collaborate with providers throughout LCI’s contracting and certification processes.
Work with Provider Representatives to proactively solicit new 1–2 bed AFH providers to meet current and projected member needs.
Support continuous improvement by evaluating systems, providing honest feedback, and being open to and supporting organizational change.
Maintain professional objectivity and promptly disclose actual or potential conflicts of interest or other circumstances that could affect or appear to affect impartial certification activities.