Program Manager II (Director of Targeted Oversight) / 60020631

Full Job Description

Are you the One? We are looking for a Program Manager II (Director of Targeted Oversight), who reports directly to the Assistant Bureau Chief of Managed Care and oversees a team focused on targeted Managed Care Organization (MCO) oversight. This includes the following areas of compliance monitoring: encounter submissions, provider network adequacy, member grievance and appeals, service authorizations, provider disputes, and MCO subcontracting arrangements. The position aligns managed care policy and reporting requirements, ensuring that MCOs are following federal and state regulations and laws, and the agency’s requirements under the SCDHHS Strategic Plan and MCO Contract. This position will also have responsibility as the business owner for external vendor contracts as needed to support oversight of regulatory and MCO requirements. The Director of Targeted Oversight is responsible for frequent collaboration with internal and external stakeholders (Medicaid and Dual Managed Care Plans, SCDHHS, CMS, etc.) to ensure the effective provision of services and operations under Medicaid and related programs.

Under the supervision of the Assistant Bureau Chief, uses Federal regulations, State Regulations, SCDHHS Strategic Plan, the Managed Care Contract, and Managed Care Report Companion Guide to develop specific deliverables to be monitored by the Office of Targeted Oversight staff.

Works with the Managed Care Contract Writer and other internal stakeholders to ensure the Managed Care Contract and associated Report Companion Guide accurately reflect reporting requirements and are updated to meet requirements and further the strategic goals of the agency.

Oversees and works with Provider Network Analyst and SCDHHS vendors/contractors on routine Managed Care Provider Network analysis.

Ensures that the MCOs are accurately reporting contracted network providers to SCDHHS.

Deficient network adequacy results will be handled as described in the MCO contract which includes a progressive set of increasing sanctions.

Compares and validates required data reports are submitted as defined by the MCO Contract and Report Companion Guide. Reviews reports for discrepancies and accuracy.

Analyzes the results of submitted MCO reports, comparing the data from each MCO looking for patterns and outliers between each MCO.

Creates a health plan score card with the results of the MCO reporting for internal stakeholders. Follows up with the MCO when discrepancies or outliers are found in the data.

The actions may include progressive sanctions as necessary to modify MCO behavior. Reviews and validates internal reporting by Managed Care data analyst.

Oversees quarterly and annual reports submitted by the MCO’s regarding Grievance and Appeals, Service Authorizations, and Provider Disputes.

Ensures that MCO’s are providing accurate and timely reports and meet contractual and/or regulatory guidelines.

Deficiencies in these areas of oversight will be addressed as described in the MCO contract, which includes a progressive set of increasing sanctions.

Oversees monitoring and analysis of MCO Encounter Data through quarterly and annual reports submitted by MCO’s and engagement with EPS.

Ensures that MCO’s are providing accurate and timely reports, meet contractual and/or regulatory guidelines, and identified key performance indicators as related to encounters submitted by MCO’s.

Deficiencies in these areas of oversight will be addressed as described in the MCO contract, which includes a progressive set of increasing sanctions.

Performs fundamental supervisory and leadership functions in accordance with Department policies and procedures, best practices and Federal and State rules and regulations, especially with regard to Equal Employment Opportunity Commission (EEOC) standards.

Maintains an effective organizational team and motivates staff toaccomplish mission critical operations and objectives. Promotes workforce engagement.

Leads or supports other projects proactively or as assigned by Agency leadership. Projects may require driving to location outside of regular office location. Continuously engages in process improvements to support Agency, Division, and Bureau-wide strategies, objectives, and initiatives.

• 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.

Requirements

A Bachelor’s Degree in Health Care, Health Administration, Public Health, Public Administration, Business, or a related field and three (3) years of experience directly related to healthcare delivery systems and/or managed care and two (2) years of supervisory experience or demonstrable experience leading teams required.

PREFERRED QUALIFICATIONS: Master's Degree in Health Care, Health Administration, Public Health, Public Administration, Business, or a related field. Five (5) or more years of work experience overseeing contract management staff. Experience working with Medicare and/or Medicaid programs.

Additional Requirements:

• Valid driver's license.
• Occasional overnight travel.
• Lifting requirements: 20 lbs.

Qualifications

• Understanding of managed care reimbursement methodologies, vendor procurement processes, and value-based contracting initiatives.
• Knowledge of SCDHHS’s mission, programs, objective and strategic plan.
• Knowledge of SCDHHS’s organizational structure, the people who manage the work, and the processes applicable to government work.
• Ability to interpret and apply rules, regulations and contractual requirement.
• Ability to make presentations and prepare reports.
• Ability to thoroughly research large quantities of information and produce sound recommendations to executive leadership.
• Knowledge of and ability to implement management principles.
• Ability to Manage work and provide guidance to employees.

Additional Information

Please complete the State application to include all current and previous work history and education. A resume will not be accepted nor reviewed to determine if an applicant has met the qualifications for the position. Supplemental questions are considered part of your official application for qualification purposes. All applicants must apply online. All correspondence from the Office of Human Resources will be through electronic mail.

The South Carolina Department of Health and Human Services is committed to providing equal employment opportunities to all applicants and does not discriminate on the basis of race, color, religion, sex (including pregnancy, childbirth or related medical conditions, including, but not limited, to lactation), national origin, age (40 or older), disability or genetic information.