Provider Compliance Manager (Medicaid Health Systems Administrator 1)

Job Overview

The Ohio Department of Medicaid is seeking a compliance professional to be a part of our Network Management team.

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.

Qualifications

• 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).
• Or 12 months experience has Medicaid Health Systems Specialist, 65293, may be substituted for the experience required, but not for the mandated licensure, if required.
• Note: education & experience is to be commensurate with approved position description on file.
• 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.
• Or equivalent of Minimum Class Qualifications for Employment noted above may be substituted for the experience required, but not for the mandated licensure.

Skills

• Considerable computer systems experience
• Strong ability to interpret and operationalize Federal and State policy
• Health Administration
• Compliance Enforcement
• Verbal Communication
• Written Communication

Pay & Schedule

• Compensation: $40.40/hour
• Schedule: Full-time
• Work Hours: 8:00 am - 5:00 pm

This response is AI-generated, for reference only.