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ProMedica Health System Senior Medicaid Compliance Specialist- Full time - Days in Maumee, Ohio

The Senior Medicaid Compliance Specialist is responsible for designing, planning, and executing compliance monitoring and/or audits to verify compliance with ODM contractual requirements, NCQA standards, and legal and regulatory obligations.

Primary Duties: essential duties are denoted with ►

► 1. Remain current on compliance requirements and upcoming changes for Medicaid line of business. Assist with the content, implementation and delivery of annual and ad hoc ODM contract compliance training. Responsible for annual policy review, annual HIPAA audits and coordinating all ODM external quality reviews.

► 2. Identify compliance risk areas and assist with the development and implementation of policies and corrective action plans where indicated. Responsible of maintaining and monitoring the Medicaid contract compliance dashboard.

► 3. Prepare written reports summarizing audit findings, report such findings to the Associate Vice-President , Medicaid Operations, Director, Regulatory Compliance, and Medicaid Operations Oversight Committee.

  1. Responsible for tracking, monitoring and coordinating resolution of ODM member and provider complaints.

  2. Serves as the departments Delegation Oversight representative and is responsible for monitoring delegated administrative services and established performance guarantees.

  3. Coordinates Family Advisory Council activities per ODM requirements and serves as Medicaid subgroup lead on the Service Excellence Council to ensure CAHPS results meet ODM and NCQA requirements.

  4. Interface with regulatory agencies and represent the Medicaid plan at internal and

external meetings as directed.

  1. Other duties as assigned.

General Information/Qualifications: essential qualifications are denoted with ►

► 1. Bachelor’s Degree in Business, Public or Health Care Administration field required. Master’s degree in a related area preferred.

  1. Three to five plus years of experience in a Medicaid–serving HMO with working knowledge of county and state Medicaid managed care program processes and requirements preferred.

► 3. Ability to identify through investigation and analysis underlying causes and contributing factors to areas of weakness and compliance problems identified.

► 4. Ability to develop and perform follow-up compliance monitoring and/or audits to evaluate the implementation of prescribed corrective actions.

► 5. Ability to research and understand compliance obligations of substantial complexity, including state and federal statutes and regulations; must possess the ability to convert compliance regulations into a logical and practical audit tool or scope document.

► 6. Demonstrated technical knowledge of health insurance, managed care and government programs compliance/regulatory matters required.

  1. Excellent verbal and written communications skills sufficient to interact will all levels of employees required.

  2. Ability to plan, coordinate, and organize multiple priorities with minimal supervision.

  3. Experience using Microsoft Office programs, especially Excel, Word, and Power Point required.

► Indicates essential functions of the job.

** Weight requirement according to the Department of Labor’s dictionary of occupational titles.

The above list of duties is intended to describe the general nature and level of work performed by the incumbent. It is not to be construed as an exhaustive list of duties performed by the incumbent.

Requisition ID: 60151