Program Coordinator Ii / 60013311 Jobs

Job Responsibilities

The Agency's mission is to be boldly innovative in improving the health and quality of life for South Carolinians.

This is position is located on the Program Integrity/SURS, Richland County.

Specific Job Functions And Responsibilities Include

Are you the One. We are looking for a Program Coordinator II who will, in Medical Service Review at the South Carolina Department of Health and Human Services, works to detect, investigate and identify instances of suspected waste, fraud or abuse of providers in the Medicaid Program.

• Learn and utilize the current (BIS) Business Information Systems (SAS, MMIS etc.) and SURS department. Have the ability to develop special reports in accordance with current health trends and practices utilizing requisite nursing/dental/professional medical knowledge. Set up, run DCRs, and focused reports as needed in SAS. Be able to utilize SAS to identify providers with egregious billing by researching Fraud Frame Work. Conducts evaluation and analysis of provider statistical profiles and detail claims reports generated by SURS/SAS reporting system. Be able to research and triage Alerts in SAS Fraud Frame Work. The first line review of data includes analysis and evaluation of exception criteria and profile reports as well as generating reports of paid claims data.
• Coordinate or schedule an informal conference to discuss review findings when requested by the provider and defend cases in fair hearing. Coordinate pre-hearing meeting with the pertinent agency staff to include Office of General Counsel and program area representative. Document the informal conference or appeals process. Refer providers to other agencies, Managed Care Organizations or the relevant licensing board as deemed appropriate.
• Oversee all DentaQuest (DQ) provider audits. Approve providers for audit selected by Denta Quest. Approve DentaQuest letters prior to sending to providers. Make recommendations on DentaQuest cases where potential fraud may require a referral to law enforcement. Defend DentaQuest case audits in fair hearing as necessary. Tracks all DentaQuest audits in OnBase.
• Conducts and coordinates quarterly case update meetings with PI and DentaQuest. Coordinates with SCDHHS dental program area staff on dental policy.
• Evaluate paid claims history data and determine the following: 1) patterns of practice and adherence to Medicaid program policy and procedures; 2) research information and make decisions utilizing nursing/dental/medical knowledge and expertise in evaluating health delivery patterns of individual providers and specialties; 3) use appropriate methodology to conduct comparison studies, focus reviews, and random sampling, review universe of claims, self-audit, line by line sample or random sampling.
• Coordinates case actions with supervisor, program area staff and a consultant when indicated. Complete provider notifications of results/findings letters. Identify and describe the provider's aberrant billing pattern/billing errors within the letter and on the Detailed claims report, cite and/or include in the initial findings packet, the policy which validates the errors and make provider recommendations to prevent the improper billing from occurring in the future. Send educational letters as appropriate. Monitors case progression at 15 day and 35 day intervals and respond to providers as necessary.
• Develop case reviews to include as determined 1) conduct unannounced onsite visit and obtain medical records, 2) Request medical records 3) send provider/recipient survey letters 4) send provider self-audit letter, 5) request additional information or documentation or 6) make telephone calls to recipients to verify services 7) Co-ordinate and correspond case actions with Managed Care Organizations, 8) Co-ordinate and correspond cases and complaints with the Investigator 9) Formulate monthly reports utilizing Onbase. Review all information received and do a comparison review between the Medicaid paid claims, applicable Medicaid rules, regulations and policy and all documentation or information obtained. Verify appropriateness and medical necessity of services billed to Medicaid. Determine if fraud referral is warranted and coordinate with supervisor to complete referrals to MFCU (Office of the Attorney General) when fraud is suspected.

Benefits

The South Carolina Department of Health and Human Services offers an exceptional benefits package for FTE and TGE positions that includes

• State Retirement Plan and Deferred Compensation Programs.
• 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.

Minimum And Additional Requirements

An associate degree with at least two (2) years of relevant Utilization review experience

or

A bachelor’s degree and relevant clinical Dental program experience.

An equivalent combination of experience and education may be considered with prior State Human Resources approval.

Additional Requirements

• Lifting requirements: 20 lbs.
• Overtime and/or weekend work with Deputy approval.
• Requires holder to drive routinely.
• Sitting or standing for long periods of time.

Preferred Qualifications

• Ability to interpret and apply laws, regulations, dental policies and procedures.
• Knowledge of laws, regulations, dental policies and procedures relevant Dental Program.
• Ability to exercise judgment and discretion on dental reviews.
• Ability to communicate effectively.
• Dental background and experience strongly preferred along with SC RDH license.
• Ability to establish and maintain effective working relationships.
• Maintain a CURRENT SC RDH License.

Additional Comments

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.