Provider Compliance Manager (Medicaid Health Systems Administrator 1)

State of Ohio • Columbus, OH

2d • Onsite

About The Position

The Ohio Department of Medicaid is seeking a compliance professional to be a part of our Network Management team. As a provider compliance team member your responsibilities will include: Developing and managing documentation for Administrative, State, and Federal criminal cases and testifying. Monitoring Federal and State policy and regulations to ensure Medicaid provider compliance. Developing and overseeing procedures to support Federal and State Policy based on program initiatives. Overseeing the notification of proper entities of provider closures (e.g., Sister Agencies, Managed Care Entities, Clinical) to ensure member safety and continuity of care. Receiving correspondence from State and federal entities regarding credible allegations of fraud, indictments, convictions, exclusions, investigations etc. and making determinations based on information received for next steps. Working closely with ODM legal and other internal partners to make recommendations (e.g., suspension or termination of provider contracts) Respond to requests for state and federal audits. Managing state and federal data bases. The preferred candidate will have considerable computer systems experience and the strong ability to interpret and operationalize Federal and State policy.

Requirements

• Completion of graduate core program in business, management or public administration, public health, health administration, social or behavioral science or public finance; 12 mos. exp. in the delivery of a health services program or health services project management (e.g., health care data analysis, health services contract management, health care market & financial expertise; health services program communication; health services budget development, HMO & hospital rate development, health services eligibility, health services data base analysis).
• If position oversees assessment or reassessment of clinical appropriateness of services &/or payment policies &/or related issues in regards to Medicaid health services delivery, incumbent must also have current & valid license as registered nurse as issued by Ohio Board of Nursing, pursuant to Sections 4723.03-4723.09 of Ohio Revised Code.
• Considerable computer systems experience.
• Strong ability to interpret and operationalize Federal and State policy.

Nice To Haves

• 12 months experience has Medicaid Health Systems Specialist, 65293, may be substituted for the experience required, but not for the mandated licensure, if required.
• Equivalent of Minimum Class Qualifications for Employment noted above may be substituted for the experience required, but not for the mandated licensure.

Responsibilities

• Developing and managing documentation for Administrative, State, and Federal criminal cases and testifying.
• Monitoring Federal and State policy and regulations to ensure Medicaid provider compliance.
• Developing and overseeing procedures to support Federal and State Policy based on program initiatives.
• Overseeing the notification of proper entities of provider closures (e.g., Sister Agencies, Managed Care Entities, Clinical) to ensure member safety and continuity of care.
• Receiving correspondence from State and federal entities regarding credible allegations of fraud, indictments, convictions, exclusions, investigations etc. and making determinations based on information received for next steps.
• Working closely with ODM legal and other internal partners to make recommendations (e.g., suspension or termination of provider contracts).
• Respond to requests for state and federal audits.
• Managing state and federal data bases.

Benefits

• Medical Coverage
• Free Dental, Vision and Basic Life Insurance premiums after completion of eligibility period
• Paid time off, including vacation, personal, sick leave and 11 paid holidays per year
• Childbirth, Adoption, and Foster Care leave
• Education and Development Opportunities (Employee Development Funds, Public Service Loan Forgiveness, and more)
• Public Retirement Systems ( such as OPERS, STRS, SERS, and HPRS ) & Optional Deferred Compensation ( Ohio Deferred Compensation )

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level