Safety Net (SN) Compliance Specialist

company•City of Rochester, NY

11d

About The Position

The Safety Net (SN) Compliance Specialist develops and executes the Health Plan’s Health Home (HH) Performance Oversight program for Medicaid enrolled adults and children. The Incumbent will ensure that the program is compliant with New York State (NYS) Department of Health Medicaid Managed Care Model Contract, the HH Standards and Requirements for Health Homes, Care Management Providers, and Managed Care Organizations. The SN Compliance Specialist, with oversight from management, will facilitate the Plan’s oversight of the HH and the HH service providers. The incumbent will develop strategy to capitalize on opportunities to attain best practice. This role will also assess impact of regulatory and Model Contract changes and ensure changes are operationalized in accordance requirements and timelines.

Requirements

Three or more years of progressive product/project management or process improvement experience.
Bachelor's degree in relevant field with two years of experience preferred. A combination of advanced education and experience may be considered.
Demonstrated knowledge of state government programs such as Medicaid.
Proficiency in data visualization and reporting tools such as Excel, Power BI and Cognos.
Strong analytic skills and ability to interpret complex healthcare data.
Strong written and oral communication and group presentation skills. Skillful in assessing an audience and delivering/presenting complex information in an easy-to-understand format.
Strong organizational and project leadership/management skills. Ability to manage multiple priorities simultaneously.
Ability to work well with all levels of management.

Responsibilities

Responsible for development and execution of the SN HH monitoring program and reporting.
Administers the HH auditing program, which may include a chart review, to assess, build out program metrics, monitor program metrics, and provide a summary for management to review on program performance.
Oversees development and monitoring of corrective action plans, if needed, to ensure regulatory compliance.
Maintains centralized documentation for all HH oversight related activities.
Maintains all EHP SNPS HH policies, procedures, and standardized communications such as member welcome letters.
Acts as back-up and single point of contact for Health Home and state regulatory issues.
Assesses changes in the state and federal regulatory landscape including NYS budgetary actions, Strategic Roadmaps, and Federal Waivers.
Identifies emerging trends and their implications and develops plans to address.
Collects, reviews, analyzes, and summarizes claims data (gaps in care, Emergency Department and Inpatient admissions) demographic information, performance data, encounter data, and billing trends.
Produces internal reports and summaries to identify actionable trends/insights to monitor program effectiveness and any recommended enhancements.
Works closely with Health Home Lead Agencies, Case Management Agencies, Local Department of Social Services (LDSS), and Foster Care Agencies.
Establishes good working relationship with agency contacts.
Produces and distributes daily reports to the lead Health Homes.
Incumbent will become proficient in use of the Psychiatric Services and Clinical Knowledge Enhancement System for Medicaid (PSYCKES-Medicaid) to support quality improvement and clinical decision-making.
Incumbent will become proficient in use of the Medicaid Analytics Performance Portal (MAPP) Health Home Tracking System.
MAPP is a performance management system that provides tools to the Health Home network to support providing care management for the Health Home population.
Works in collaboration with member services, SN care management, SN utilization management, provider relations, customer advocacy unit, and special investigations unit.
Addresses any Health Home issues or member complaints, working collaboratively to achieve timely and effective resolution.
Monitors the Health Home mailbox and respond promptly to inquiries or escalates issues as appropriate.
Assists with enrollment, disenrollment, and access to care issues (including facilitation of single case agreements when applicable).
Participates in meetings such as the Health Plan’s quarterly meetings with HH network to review the data performance issues through agendas, case summaries, and reporting. NY State sponsored meetings and summaries provided to management and input given to DOH proposed contract or procedural changes.
Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements.
Develops a "culture of ownership" and risk management excellence in the department.
Promotes communication and information flow through all needed levels of department, with external stakeholders and Health Plan leadership that will allow for input into SN BH Segment strategy planning and execution.
Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
Regular and reliable attendance is expected and required.
Performs other functions as assigned by management.