Hybrid Provider Review Manager (00056363) en Georgia Department of Community Health
Georgia Department of Community Health · Atlanta, Estados Unidos De América · Hybrid
- Professional
- Oficina en Atlanta
About the Department
The Georgia Department of Community Health (DCH) is one of Georgia's four health agencies serving the state's growing population of over 10 million people. DCH serves as the lead agency for Medicaid, oversees the State Health Benefit Plan (SHBP) and Healthcare Facility Regulation, impacting one in four Georgians.
Through effective planning, purchasing and oversight, DCH provides access to affordable, quality health care to millions of Georgians, including some of the state's most vulnerable and under-served populations. Six enterprise offices support the work of the agency’s three program divisions. DCH employees are based in Atlanta, Cordele and across the state.
DCH is committed to providing superior Customer Service and Communication, embracing Teamwork and fostering Accountability to ensure that our internal and external customers and stakeholders feel included, respected, engaged and secure.
The Georgia Department of Community Health (DCH) is currently seeking qualified applicants for the position of Provider Review Manager, with the Office of Inspector General, Program Integrity Unit. This is a hybrid position that requires in-office and remote work with the approval of the supervisor. The days and frequency in the office can change at any time during employment based on the business needs of the organization. This is a full-time, unclassified position categorized under the Fair Labor Standards Act (FLSA) as exempt.
This position provides critical support functions within the Program Integrity Unit and the Office of Inspector General, which helps safeguard the agency from fraud, waste, and abuse. The selected candidate will be responsible for managing three (3) direct reports charged with oversight of provider self-disclosure, prepayment, and Beacon utilization reviews for the Fee-for-Service Medicaid program.
The Provider Review Manager provides guidance and feedback to the team to ensure adherence and timeliness of business processes for the Program Integrity Unit. The Provider Review Manager monitors provider billing for inactivity and notifies provider enrollment when suspension or termination is warranted. The Provider Review Manager collaborates with Alliant Health Solutions (contracted vendor) to educate providers on prepayment review and implement prepay restrictions in GAMMIS.
The Provider Review Manager also collaborates with Department of Behavioral Health and Developmental Disabilities and the Medicaid Fraud and Patient Protection Division during monthly meetings to identify providers for prepayment review, sanction, or preliminary investigation. The Provider Review Manager works closely with the Assistant Directors to monitor monthly and quarterly managed care reports to ensure program integrity activities such as investigations, overpayments, and prepayment review are enforced in a timely manner in accordance with managed care contracts and policies and procedures for Medicaid.
Position Duties
The Provider Review Manager shall perform the following duties and responsibilities:
- Coordinates with Divisions within the agency to effectively monitor Fraud, Waste, and Abuse.
- Collaborate with contracted vendors, staff, and CMOs to ensure Medicaid providers are following Medicaid policies and procedures, state, and federal laws.
- Track and monitor managed care monthly and quarterly reports to ensure oversight of CMOs' Program Integrity activities identified in managed care contracts.
- Participates in the planning, coordination, development and implementation of long-range goals and objectives for the Office of Inspector General.
- Coordinates on site visits at provider locations to facilitate utilization reviews.
- Effectively communicates with external and internal stakeholders at monthly meetings to mitigate fraud, waste, and abuse in the Georgia Medicaid program.
- Leads special projects and participates in audits to ensure payment integrity of claims billed to the Medicaid program.
- Performs claims data analysis to identify aberrant billing trends for providers enrolled in the Medicaid program.
- Collaborates with Assistant Directors to detect, prevent, and investigate providers for fraud, waste, and abuse.
- Performs case management functions for utilization reviews assigned to managed care plans, vendors, and Program Integrity staff.
Minimum Qualifications
Preferred Qualifications:
Preference will be given to candidates who have a background in healthcare and, in addition to meeting the qualifications listed above, possess the following:
- M.S. degree in Nursing, Psychology, Healthcare Administration, or similar clinical programs.
- Certified Fraud Examiner or Accredited Health Care Fraud Examiner.
- Experience with monitoring, investigations, case management, identifying and reviewing claims and auditing of government health care programs.
- Experience in the preparation, review and delivery of formal medical/investigative reports including relevant statistical summaries and qualitative analysis of findings.
- Knowledge of statistical data and reporting.
- Knowledge of Georgia Medicaid and the MMIS System.
- Knowledge of both Fee for Service and Managed Care Claims data.
Key Competencies:
- Minimum of three years' experience conducting fraud, waste, and abuse reviews/investigations.
- Minimum of three years supervisory experience.
- Knowledge of Medicaid policies and procedures.
- Minimum three years’ experience writing/reviewing fraud reports/investigations.
- Experience with monitoring performance guarantees in vendor contracts.
- Experience working with Medicaid and/or Medicare claims.
- Knowledge of and history of work with medical claims and data.
- Proficient in Excel, Access, Data Analysis and Microsoft products.
- Must possess excellent writing skills.
- Ability to mentor and perform staff development to identify and address performance issues.
- Ability to implement courses of actions to ensure compliance with federal and state regulations, and Medicaid policies and procedures.
- Ability to organize and manage program areas to mitigate fraud, waste, and abuse in the Medicaid program while protecting the payment integrity of claims.
- Ability to set goals with defined milestones to measure progress to monitor key performance metrics.
- Ability to counsel subordinates when necessary and develop performance improvement plans to address opportunities for improvement.
Attached herein for reference is the Job Catalog – General Support, GSM011 available at:
http://doas.ga.gov/human-resources-administration/compensation/job-code-catalogs
Other Qualifications
Due to the volume of applications received, we are unable to provide information on application status by phone or e-mail. All qualified applicants will be considered, but may not necessarily receive an interview. Selected applicants will be contacted by the hiring agency for next steps in the selection process. Applicants who are not selected will not receive a notification.
THIS POSITION IS SUBJECT TO CLOSE AT ANY TIME ONCE A SATISFACTORY APPLICANT POOL HAS BEEN IDENTIFIED. APPLICATIONS WITHOUT WORK EXPERIENCE LISTED WILL NOT BE CONSIDERED. CURRENT GEORGIA STATE GOVERNMENT EMPLOYEES WILL BE SUBJECT TO STATE PERSONNEL BOARD (SPB) RULE PROVISIONS. THE POSITION MAY BE FILLED AT A LOWER OR HIGHER POSITION LEVEL.
This position is unclassified and employment is at-will. Candidates for this position are subject to a pre-employment background history and reference check.
For more information about this job and other career opportunities with DCH, please visit our Careers Page:https://www.governmentjobs.com/careers/dchga.
