Provider Certification Specialist (Org Wide)

Lakeland Care Incorporated•Fond Du Lac, 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 AFH providers, community agencies, and community representatives, while ensuring provider documentation is maintained and updated promptly. The position supports the Provider Relations Division through onsite provider visits and by monitoring and analyzing quality-related data to ensure providers meet contractual requirements. With a multi-county focus, the Specialist works closely with both Provider Relations Managers to ensure contracted AFHs meet certification requirements, AFH standards, and home and community-based services (HCBS) setting requirements. Lakeland Care is a Wisconsin-based nonprofit managed care organization serving eligible frail elders and individuals with physical, intellectual, or developmental disabilities through Wisconsin’s Family Care program. It serves 22 counties and has 10 offices in Central to Northeast Wisconsin.

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, and regulatory systems, and provider network contracting in a managed care model.
Experience, training, skills, or aptitude in collaborating with potential or current AFH providers; interpreting contract language, standards, and requirements; analyzing data; providing education and training to improve outcomes; and presenting to groups.

Responsibilities

Collaborate in developing provider certification and contracting standards and consistent processes for ongoing compliance with DHS contracting standards.
Maintain a thorough understanding of regulations for certification of 1–2 bed Adult Family Homes and applicable contracting requirements.
Attend training required by DHS for certifying agencies and follow the training plan.
Conduct certification and recertification activities objectively and consistently, based on documented evidence, applicable DHS standards, LCI requirements, and established procedures.
Maintain complete, accurate, and timely records of certification activities, deficiencies, corrective actions, approval conditions, exceptions, and other actions affecting a home's certification status.
Use established procedures and professional judgment to assess compliance with administrative, operational, physical-environment, life-safety, quality-of-care, and quality-of-life requirements; identify and communicate 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 circumstances requiring further review, inspection, corrective action, or other certification action.
Conduct required onsite certification and recertification reviews, validate application information and supporting documents, observe homes and their environments, 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 could jeopardize the health and safety of residents in 1–2 bed AFHs.
Ensure providers have adequate training and training resources.
When requested, document AFH exceptions to requirements in writing and report exception requests and granted exceptions to DHS quarterly as required.
Communicate effectively with contracted providers and other LCI departments to support and improve organizational practices.
Respect differing opinions and concerns and value diversity in thought and action.
Work with the Contracting and Development Manager to provide training opportunities or educational resources on certification and recertification requirements for AFHs and LCI staff as needed.
Attend professional meetings, including community provider association meetings, as assigned, and train or update other Provider Relations team members as appropriate.
Collaborate with providers on LCI contracting and certification processes.
Work with Provider Representatives to proactively solicit new 1–2 bed AFH providers in response to current and projected member needs.
Support continuous improvement by evaluating systems, providing honest feedback, and remaining open to and supportive of 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.