Summary of Job
Responsible for the oversight of cross functional activity related to Medicaid audits conducted by OMIG, AIG and their agents for Medicaid, Child Health Plus, HARP and other State Sponsored (“Medicaid”) lines of business. Responsible for ensuring that EmblemHealth and its delegates comply with encounter data submissions & reconciliation as well as retroactive enrollment audits for Medicaid, Child Health Plus, HARP and other State Sponsored (“Medicaid”) lines of business. Lead collaboration efforts with Enrollment, Compliance, Finance, Actuarial, Legal, Claims, and Pharmacy to ensure accurate and comprehensive delivery of audit requirements.
Responsibilities
• Lead cross‐functional activity related to Medicaid Audits conducted by DOH, OMIG, HMS and AG for audit types: Third Party Health Insurance; EmblemHealth and external Plans, Retroactive disenrollment (Incarcerated, deceased), Supplemental Maternity capitation, Family Planning, Nursing home placement, Foster Care, and Multiple Client Identification Number.
• Manage the tasks and projects exclusive of the OMIG audits themselves (handled by External Regulatory Audit (in Compliance function).
• Track findings identified by the auditors; ensure that all issues are addressed in full before the required deadline.
• Evaluate the impact of each finding, stratify findings in terms of impact on EmblemHealth, and provide appropriate recommendations to address each finding as needed, based on operational best practices and sound judgment.
• Provide analysis and recommendations to strengthen operations to limit current & future liability.
• Interface with external resources (Trade Associations (HPA/Manatt), outside counsel, OMIG, DOH).
• Partner with finance and business owners to ensure appropriate reserving for future audits during monthly financial close.
• Lead the collection, retention, and submission of encounter reimbursement offsets.
• Perform data analysis, cross referencing, etc., to facilitate accurate dispute analysis
• Partner with External Regulatory Audit function to manage incoming Medicaid regulatory communications, review & approve narrative responses to auditors.
• Lead cross collaboration with all operational departments impacted by audit activities to implement best practices.
• Produce and present reports to the Assistant Vice President on a regular basis on the status of all projects.
• Maintain a working knowledge of relevant issues, laws, regulations, and industry best‐practices to ensure operational.
areas across the Medicaid lines of business are compliant.
• Review/manage BHET/MMCOR liabilities by recommending and implementing mitigation strategies for prior time periods and for current/future time periods.
Qualifications
• Bachelor’s degree in healthcare, business administration, law, or related field; Master’s Preferred
• 10 – 12+ years’ experience in compliance‐related matters, preferably in the health care industry (Required)
• 3+ years’ experience with NYS Medicaid covering OMIG, MMCOR, or EIS/APD (SP)
• Staff and process management experience (Required)
• Understanding of the healthcare environment as it relates to liability potential (Required)
• Extensive experience with federal and/or state regulatory guidance (Required)
• Excellent communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences (Required)
• Proficiency with MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.) (Required)