$4,839.86 - $6,236.95 Monthly
048-Div. of Healthcare Financing - Provider Operations
Description and Functions
Open Until Filled
This position is responsible for managing the Business Operations Function to support the successful delivery of Program Integrity (PI) goals and initiatives to minimize fraud, waste, and abuse in the State Medicaid system.
Human Resource Contact: 307-777-6780
ESSENTIAL FUNCTIONS: The listed functions are illustrative only and are not intended to describe every function which may be performed in the job level.
+ Complete oversight of Business Operations personnel, duties, and functions.
+ Establish goals and performance expectations for staff, prioritize and assign work to staff, review and approve work product, conduct mid-year review and annual performance appraisals of staff, provide coaching to employees on development opportunities, conduct staff trainings, communicate disciplinary actions, and resolve issues within the Operations Function.
+ Develop and conduct provider outreach training(s) on Medicaid for healthcare practitioners, billing personnel and state employees.
+ Monitor quality assurance of fiscal agent activities to ensure compliance with contract for program areas; monitor and assess payment system, processes and edits to ensure validity an reliability.
+ Ensure the effective application and ongoing performance of internal controls. Make recommendations, as necessary, to the Quality Assurance Manager regarding necessary changes to ensure optimal functioning of the Program Integrity Unit. This includes oversight of recoveries and case tracking/case aging, management of overpayment collection and correct application of overpayments, proper application of credit balance tracking and aging including coordination with fiscal agent staff, work with the Attorney General's office on settlement actions, and oversight of supporting policies and procedures.
+ Administer payment plan process, including coordination with legal analyst, State Medicaid Agent, and Attorney General.
+ Manage provider payment suspensions, provider terminations and required coordination with the State's Fiscal Agent.
+ Coordinate with the Audit Function to ensure the accurate application of State payment systems, processes, and edits.
+ Management of referral process and oversight of fraud, waste, and abuse referrals. Ensure proper internal processes and procedures for managing and responding to the receipt of fraud, waste, and abuse referrals.
+ Manage the tracking, and status updates of all referrals made to Medicaid Fraud Control Unit (MFCU), Recovery Audit Contractor (RAC), and other law enforcement agencies.
+ Manage the collection of overpayments received from these referrals. Manage the coordination with the Pharmacy Program to ensure the proper application and processing of pharmacy recoveries. Explanation of Medicaid Benefits (EOMB) processing, tracking, and research. Oversee attestations of false claims over $5,000,000.
+ Maintain expert level knowledge of Federal and State policy and regulation that grant the authority of the PI functions. Coordinate distribution of updated policy, procedures, manuals, and bulletins to ensure PI unit employees are knowledgeable and current on policy changes.
+ Ensure compliance with related Federal and State policy and regulations.
+ Recommend policy revisions, draft revisions, and review policies, to ensure compliance with State and Federal regulations.
+ Assist Quality Assurance Manager with updating administrative rules, processes, procedures and revising the State Plan as required to align with Code of Federal Regulations (CFR). Provide assistance in the design, development, and implementation of new and existing policies.
+ Approve the drafting and distribution of PI bulletins for dissemination to stakeholders.
+ Monitor programs utilizing Medicaid funds to ensure that goods and services delivered comply with Federal and State policy.
+ Accountable for critically important fiscal reporting that ensures the State maintains eligibility for Federal Financial match on Medicaid programs in accordance with CFR.
+ Oversee and ensure compliance on credit balance aging/tracking, financial actions related to payments, recoveries, write offs, restitution for fraud cases, and global settlements, and management of CMS-64. Coordinate with the PI manager the
collection of data required for HealthStat updates. Coordinate the correction and development of related corrective action plans for actionable findings identified through PERM review.
+ Management of contracts as assigned by the Program Integrity manager. Support procurement attempts in conjunction with Department of A&I.
+ Draft and submit State Plan Amendments to CMS as needed to ensure adequate response to RFP.
+ Participate in contract negotiations as needed, and oversee selected vendor to ensure successful delivery of contract deliverables.
+ Anticipate contract close and prepare for transition ahead of subsequent procurements.
+ Oversee the completion of the Single Statewide Audit of Medicaid payments.
+ Provide program information to be used during audits and analysis, and ensure successful completion of audit activities.
+ Communicate audit findings to State Medicaid Agent, coordinate responses to findings with other unit managers.
+ Ensure audit is performed in accordance with CFR and the recovery process is coordinated with appropriate unit staff.
+ Knowledge of State and federal government functions, procedures, policies, rules, and laws.
+ Knowledge of Medicaid functions, procedures, policies, rules, and laws.
+ Knowledge of healthcare delivery systems benefits, resources, and policy, including government financed and private systems.
+ Knowledge of fraud and abuse detection methods and systems.
+ Knowledge of State Personnel Rules.
+ Skill in research and analysis of complex problems, identification of options and solutions, evaluation of results, and decision making.
+ Skill in public speaking and oral and written communication, to varied audiences on complex and controversial issues.
+ Ability to establish and maintain positive working relationships with individuals and groups.
+ Ability to accept and be flexible with Federal, State, and Agency changes.
+ Ability to balance multiple demands on time and resources.
+ Ability to self-educate, both formally and informally, to remain current in areas of responsibility.
Bachelor's Degree (typically in Human Services)
1-2 years of progressive work experience (typically in Benefits and Eligibility) with acquired knowledge at the level of a Senior Quality Assurance Specialist
Education & Experience Substitution:
4-6 years of progressive work experience (typically in Benefits and Eligibility) with acquired knowledge at the level of a Senior Quality Assurance Specialist
Certificates, Licenses, Registrations:
Necessary Special Requirements
PHYSICAL WORKING CONDITIONS:
+ This position takes place in an average work environment.
+ FLSA: Exempt
048-Wyoming Department of Health - Healthcare Financing - Program Integrity Unit
Click here to view the State of Wyoming Classification and Pay Structure.
The State of Wyoming is an Equal Opportunity Employer and actively supports the ADA and reasonably accommodates qualified applicants with disabilities.
Class Specifications are subject to change, please refer to the