Georgia Department of Community Health · 1 day ago
Review and Investigations Assistant Director
Atlanta, GA
Full-time
Hybrid
Lead/Staff, Director/Executive
5+ years expThe Georgia Department of Community Health is seeking a Review and Investigations Assistant Director for its Office of Inspector General. This role involves managing a team to ensure compliance with medical reviews and overseeing program integrity activities related to Medicaid providers.
CommunitiesHealth CareMedicalPersonal Health
Responsibilities
Serve as co-business owner for vendor contracts and ensure performance guarantees and deliverables are met, and payments are processed in accordance with contractual requirements
Coordinates with Divisions within the agency to effectively monitor Fraud, Waste, and Abuse
Oversees fraud referral process and refers cases to the Medicaid Fraud Control Unit based on credible allegations of fraud
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
Conducts or participates in the development, review, revision, interpretation, and/or implementation of policies, procedures, standards, and guidelines
Oversee the development and on-going management of one or more programs or projects consistent with agency goals and objectives
Participates in the planning, coordination, development and implementation of long-range goals and objectives
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
Provides clinical expertise to DCH-OIG staff, contracted vendors, and managed care organizations to mitigate fraud, waste, and abuse related to utilization reviews
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
Qualification
Required
Bachelor's degree in operations management, business administration, or a related field which includes five (5) years in a managerial or supervisory role; or nine (9) years of related professional experience which includes five (5) years in a managerial or supervisory role; or five (5) years of experience required at the lower-level Sr Mgr, Business Ops (GSM012) or position equivalent
Minimum of three years' experience conducting fraud, waste, and abuse reviews/investigations
Minimum of two years supervisory experience
Knowledge of Medicaid policies and procedures
Minimum three years' experience writing/reviewing fraud reports/investigations
Experience in oversight of 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 product
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 analyze the operational impact of legislative and executive initiatives that impacts DCH-OIG and payment integrity of claims
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
Preferred
Candidate must be an active licensed clinician in Georgia
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
Benefits
Employee retirement plan
Paid holidays annually
Vacation and sick leave
Health
Dental
Vision
Legal
Disability
Accidental death and dismemberment
Health and childcare spending account
Company
Georgia Department of Community Health
The Georgia Department of Community Health serves as the lead agency for Georgia Medicaid and Georgia PeachCare for Kids®, and oversees the Healthcare Facility Regulation Division, State Health Benefit Plan, and State Office of Rural Health, among other divisions.
10001+ employees
Funding
Current Stage
Late StageTotal Funding
$6.9M2014-09-15Grant· $6.9M
Leadership Team
D
Debbie Hall
Chief Operating Officer
C
Chad Purcell
Chief Information Officer
Recent News
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