Managed Care Member/Provider Specialist

On April 1, 2016, the Iowa Medicaid transitioned to a managed care program, known as IA Health Link. As a result of this transition the model for service delivery and reimbursement changed from a primarily Fee-for-Service (FFS) model to a risk based Managed Care Organization (MCO) model. Today, the MCOs provide members with comprehensive health care services, including physical health, behavioral health, and long-term services and supports. Approximately 96% of all Iowa Medicaid Members are enrolled in an MCO with 4% remaining in FFS. The MCO contracts total more than $64 billion and establish health plan provider network(s) comprised of traditional Medicaid providers, behavioral care providers, nursing and ICF/10 facilities and home and community-based service providers. The MCOs are responsible for:

• Proactively address member and provider issues
• Develop and implement care plans based on Iowa Medicaid standards.
• Provide member and provider service.
• Monitor and assure the provision of quality services.
• Achieve Iowa Medicaid stated physical health, behavioral health and long-term care supports and services outcomes.
• Manage within a capitated rate.
• The development of a comprehensive panel of physical health, behavioral health and long-term care providers including facility and home and community-based services
• Reimburse providers.
• Implement strong program integrity efforts.

Each MCO Member/Provider Service Specialist is responsible for analysis of one MCO's status on all required member and provider performance expectations to assure contractual compliance. This position is integral to effective contract oversight and serves as the subject matter expert in providing consultation, analysis, and review of MCO performance.

Key responsibilities are as follows:

• Substantiate that MCO plans, operations, manuals and data related to member and providers services are contractually compliant with Readiness Review, where applicable, and ongoing analysis for program outcomes and efficiency. Propose improvements to MCO operations, manuals, and data collection.

• Prepare special reports as assigned.
• Propose improvements for MCO performance; provide oversight for process improvement implementation.
• Complete special analysis of member and provider data as assigned.
• Modified CMS service requirements, State regulations and administrative rules.
• Coordinate and work closely with MCO Account Managers: Provide analysis or other work to support MCO Account Manager in monthly meetings, participate in monthly MCO meetings, as necessary.
• Complete in-depth analysis of ad hoc, monthly, quarterly, and annual MCO reports to ensure compliance with contract regarding member and provider requirements.
• Prepare monthly, quarterly, and annual MCO member and provider reports to meet state and federal requirements.
• Continual analysis of member and provider services to ensure compliance with new or
• Perform on site monitoring visits as needed to determine program reporting compliance identified through MCO data reports.

MCO Member and Provider Subject Matter Expert responsibilities:

• Provide member/provider information to relevant Iowa Medicaid staff.
• Participate in internal and external work groups or meetings as assigned.
• Analyze impact of proposed policy or program changes.
• Research evidence-based quality of care initiatives to provide guidance and direction for future IA Health Link programs or contracts.
• Assist with development of agenda and facilitate meetings for Iowa Medicaid, Health, and Human Services leadership, MCO staff,
• Review and provide feedback to Iowa Medicaid policies impacting MCO contract requirements and performance.
• Stakeholders or other identified entities
• Research and prepare response to member and provider issues or other related requests for information; track and monitor member and provider issues to ensure solutions toward performance outcome goals.

HHS serves almost a million Iowans through health coverage, mental health and disabilities services, long-term care and treatment, and adult, children, and family services. We have a great total compensation package for all of our full-time employees, including:

Iowa Public Employees' Retirement System (IPERS)
Retirement Investors Club (RIC) (Employer Sponsored Retirement Plan)
Health, Dental and Vision Insurance
Vacation Leave
Sick Leave
Paid Holidays (9 days/year)
Flexible Spending Accounts
Life Insurance
Long-Term Disability Insurance

To learn more about benefits available to State of Iowa employees visit the benefits web page.

HHS values those with “lived experience” and encourages adults who were fostered as youth, foster parents, and/or parents who were in the HHS system to apply. Minorities, women, persons with disabilities and veterans are encouraged to apply (Hearing and Speech Impaired – Relay Iowa 1-800-735-2942 TDD).

Our agency uses E-Verify to confirm the employment eligibility of all newly hired employees. To learn more about E-Verify, including your rights and responsibilities, please visit www.dhs.gov/E-Verify.

Selectives

N/A

Minimum Qualification Requirements

Applicants must meet at least one of the following minimum requirements to qualify for positions in this job classification:

1) Graduation from an accredited four-year college or university with a degree in any field, and experience equal to three years of full-time work in management analysis or project management.

2) Seven years of full-time work experience in management analysis or project management.

3) A combination of a total of seven years of education and full-time experience (as described in number one), where thirty semester hours of accredited college or university course work equals one year of full-time experience.

4) Current, continuous experience in the state executive branch that includes two years of full-time work as a Management Analyst 2 or two and a half years as a Management Analyst 1.

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