The Medicaid Division, which accounts for approximately eleven billion dollars annually of the State’s budget, is dedicated to advancing the health, wellness, and independence of those they serve by providing access to quality care and resources statewide to more than two million Georgians.
Job Responsibilities
The Managed Care Services & Compliance Director is responsible for ensuring proper delivery and administration of managed care offerings while resolving any CMO-related issues.
Roles and responsibilities:
- Report to Service Delivery & Administration Deputy Executive Director on activities and initiatives, including escalating any risks, issues, or concerns
- Oversee all reporting functions related to care management organization contract compliance
- Serve as Medicaid Managed Care liaison with other state agencies to include the Department of Public Health, Human Services, and Behavioral Health and Developmental Disabilities
- Review and analyze federal and state laws, rules and policies to determine application to CMO contracts, operations, and/or DCH compliance
- Oversee research and response to CMO-related issues from members and providers
- Participate in resolution of operational or reporting concerns
- Oversee or directly review various error reports as well as issues from CMOs, RevMax (DFCS’ Child in Placement Eligibility Unit), GF360 Policy team, and other agencies
- Oversee member operations including member correspondence, CMO outreach, and complaints.
- Work with the state’s Accounting and Auditing firm to analyze CMO reports and determine need for correction
- Helps coordinate the CMO workshops for Medicaid Fairs
- Holds monthly CMO operations meetings to facilitate information exchange
- Supervise, plan, and review work of assigned staff and provide feedback
- Interview, hire, direct, train, evaluate the performance of, and when necessary, discipline and discharge employees
Key Skills and Qualifications:
- Education: Juris Doctor
- Significant knowledge and understanding of managed care operations and procedures. Experience working directly in managed healthcare preferred.
- Strong experience serving as a business owner of contracts with third-party vendors or sister agencies to include compliance and performance measures
- Knowledge and understanding of DCH’s managed care and fee-for-service programs and services
- Ability to establish and maintain effective working relationships with CMO’s, partner agencies, vendors and DCH Leadership
- Significant knowledge and understanding of federal, state, and CMS managed care policies and regulations
- Experience supporting implementation of a strategic plan against success metrics and the impact on related business processes
- Demonstrated experience managing staff to implement new initiatives, execute projects on time, and on budget
- Ability to guide team, manage performance and build a collaborative work environment
- Experience engaging in staff recruitment and retention activities