Audits Manager I (Reimbursements Manager - NHs AND FQHCs) / 60016587RP

This position is a re-post. Previous applicants do not need to re-apply. The Agency's mission is to be boldly innovative in improving the health and quality of life for South Carolinians. This position is located in Reimbursements, Richland County. This is an in-office role and not a telecommute or remote position.

Responsibilities

• Manage the team implementing Medicaid reimbursement policies and rate-setting methodologies for Nursing Homes (NHs) and Federally Qualifying Health Centers (FQHCs).
• Ensure provider payments are accurate, compliant with State and Federal regulations, and aligned with program goals.
• Ensure the accuracy and completeness of staff analyses and deliverables through regular review and guidance.
• Conduct desk reviews and perform rate setting activities for NHs and FQHCs to ensure alignment with Federal regulations and State Medicaid policy.
• Perform financial analyses of proposed reimbursement methodologies and rate structures for new and existing Medicaid services.
• Manage the efforts to request, collect, track, and store digital copies of Medicaid Cost Reports for NHs.
• Interpret and apply legislative regulations found in the State Plan to calculate specific and statewide Nursing Home Rates along with Swing Bed and Administrative Day Rates.
• Prepare NH Rates for submission to CMS and ensure approved rates are submitted for input to SCDHHS’ claims-handling application, Medicaid Management Information System (MMIS).
• Review team’s calculation of Nursing Home Settlements for retro-rate adjustments based on Audits or Consent Orders.
• Review NHs annual submissions of Professional Liability Claims support for compliance and calculations of amounts to reimburse NHs per the State Plan.
• Ensure accurate communication of Requests, Payments, Rate Changes, and Reimbursement Methodology changes to NHs.
• Maintain audit-ready documentation for all data sources, calculations, methodologies, approvals, and rate-setting decisions.
• Use Excel Macros and software applications to extract relevant data from both Medicare and Medicaid Cost Reports.
• Run and review Statistical Analysis System (SAS) Queries that extract claims data from MMIS’ reporting layer and ensure a proper understanding of the output.
• Prepare Upper Payment Limit Demonstration for Nursing Homes for CMS.
• Periodic review and reconciliation of Reimbursement Payment Logs for audit purposes.
• Respond to FOIA (Freedom of Information Act) Requests for NHs.
• Manage the efforts to request, collect, track, and store digital copies of both Medicare and Medicaid Cost Reports for FQHCs.
• Interpret and apply legislative regulations found in the State Plan to determine Rates for new FQHCs and ensure these rates are submitted properly for input to SCDHHS’ claims-handling system, MMIS.
• Review FQHCs Change in Scope submissions to confirm compliance with state and federal regulations.
• Calculate rate adjustments for FQHCs based on properly submitted Change in Scope requests.
• Quarterly review of staff’s determinations, calculations, and data pulled to support supplemental wrap payments that ensure FQHCs receive legislated payments for certain Fee-for-Service Dental services or certain services paid by Managed Care Organizations.
• Review staff’s monthly preparation of NH Expenditure and Utilization Reports prior to submission to the Director and Chief of the Bureau.
• Complete research to include running of SAS queries to verify and confirm completeness and accuracy based on the identification of anomalies by Management or internal and external inquiries received by the Bureau.
• Perform fundamental supervisory and leadership functions in accordance with Department policies and procedures, best practices, and Federal and State rules and regulations.
• Maintain an effective organizational team and motivate diverse staff to accomplish mission critical operations and objectives.
• Promote workforce engagement and a safe, professional, and productive work environment for all employees.
• Perform additional duties as assigned within the specified timeframe and according to the directions made available at the time of the assignment.
• Ensure all rates that the bureau sets are updated according to state and federal regulations and requirements and have been approved by executive leadership.
• Coordinate the publishing of approved rates with the Office of Communications.
• Review and monitor published rates for completeness and accuracy.

Requirements

• A bachelor's degree in accounting, business administration, finance, insurance, or a related field and experience in professional-level accounting, auditing, or financial management.
• An equivalent combination of education and experience may be accepted with prior State Human Resources approval.

Preferred Qualifications

• At least two (2) years managing accountants and/or auditors.
• Experience with Medicare or Medicaid reimbursement principles and cost report preparation.
• Knowledge of Medicaid and Federal/State regulations, rate setting methodologies, and accounting and financial management practices.
• Knowledge of standard software applications (spreadsheets, macros, databases, reporting systems, etc.).
• Knowledge of data collection, reporting standards, and documentation requirements.
• Ability to exercise sound judgment and make data-based decisions in addition to working effectively with provider organizations and partner agencies.

Additional Requirements

• Overtime and/or weekend work with Deputy approval.
• Sitting or standing for long periods of time.
• Lifting requirements: 25 lbs.
• In-office role.

Benefits

• Health, Dental, Vision, Long Term Disability, and Life Insurance for Employee, Spouse, and Children.
• 15 days annual (vacation) leave per year.
• 15 days sick leave per year.
• 13 paid holidays.
• State Retirement Plan and Deferred Compensation Programs.