Job Description
Come as you are | Become who you want to be | That is our promise.
Acknowledging the National history of systemic inequality and inequity, DMAS continues to take a stand for social justice.
DMAS remains committed to creating a more diverse, inclusive and equitable environment in Virginia by fostering excellence internally and externally in providing services to Medicaid Members and the Commonwealth.
We are driven by a core commitment to diversity, equity and inclusivity.
DMAS promotes a working environment where persons from all backgrounds and experiences are welcome, safe, and respected.
Ven como eres | Conviértete en quien quieres ser | Ésta es NUESTRA promesa.
Reconociendo la historia nacional de desigualdad e inequidad sistémica, DMAS continúa defendiendo la justicia social.
DMAS mantiene su compromiso de crear un entorno más diverso, inclusivo, y equitativo en Virginia fomentando la excelencia interna y externa en la prestación de servicios a los Miembros de Medicaid y al estado de Virginia.
Nos impulsa un compromiso fundamental con la diversidad, la equidad y la inclusión.
DMAS promueve un ambiente de trabajo donde las personas de todos los orígenes y experiencias son bienvenidas, están seguras y son respetadas.
The Department of Medical Assistance Services (DMAS) is currently seeking a Policy Integrity Analyst to provide managed care oversight in the review of program integrity strategies and provide technical assistance as needed.
This role will perform compliance reviews of Medicaid services to determine compliance with contracts/agreements in addition to Federal and State regulations and policy; Determine through medical record reviews that the criterion for reimbursement is met and services were rendered according to federal, state regulations and policy for all Medicaid programs; Identify the existence of abusive billing practices.
They will identify non-compliance, overpayments and potential fraud, abuse and waste and take necessary steps for reporting; Process referrals and complaints received, to include processing referrals to be sent to the Medicaid Fraud Control Unit (MFCU) at the Office of the Attorney General (OAG); Participate in policy/procedure development and provide training and/or technical assistance to providers, Managed Care Plans and DMAS staff.
In addition, they will conduct compliance reviews on fee-for-service and managed care provider types enrolled in the Medicaid Program, as well monitor compliance with auditing contracts and managed care plans using Federal and State regulations, DMAS policy and contract compliance.
Through reviews, they will determine that the criterion for reimbursement is met according to federal, state regulations and policy for all Medicaid programs; identify the existence of any abusive billing practices, overpayments, potential fraud, or abuse and waste, and take the necessary steps for reporting their findings.
Minimum Qualifications
Qualified candidates, at minimum, must have:Knowledge of managed care plans, principles and technical methods of medical auditing, utilization review/utilization management for Medicaid programs and contract compliance.
Knowledge of federal and state Medicaid regulations, policy and procedures.
Knowledge of the health and social service needs of children and/or disabled individuals, and others with special health care needs.
Knowledge of medical standards of treatment and medical terminology; ICD and CPT coding and clinical aspects of medical care.
Knowledge of current health care trends, quality assurance issues and health care statutes and regulations.
Skilled in the use of PC, spreadsheets, database and word processing programs as well as Medical Management Information Systems.
Demonstrated ability to analyze legislative and regulatory statutes and interpret health care contracts.
Demonstrated ability to prepare comprehensive reports and communicate effectively through presentations.
Ability to review and present complex and highly technical policy analyses.
Ability to analyze the audit findings using a spreadsheet software program.
Ability to organize and prioritize work assignments, prepare reports, develop and conduct trainingAbility to maintain the privacy and security of Protected Health Information (PHI) and other confidential information.
Ability to analyze computer-generated reports and medical records to determine the appropriateness of billing and medical necessity for and appropriateness of treatment.
Ability to work independently and to communicate effectively orally and in writing.
Ability to develop and maintain effective working relationships in order to successfully achieve core tasks.
Experience with healthcare policy development, review and revisions.
A valid Virginia driver’s license is required.
Preferred Qualifications
Special Requirements
This position is expected to work both remotely and/or in the office as driven by business needs.
Ability to work remotely is required.
The Department of Medical Assistance Services is an Executive Branch agency.
In accordance with Governor Ralph Northam’s Executive Directive Number 18, all Executive Branch employees and state contractors who enter the workplace or have public-facing work duties must disclose their vaccine status to the designated agency personnel.
Executive Branch employees who are not fully vaccinated or who refuse to disclose their current vaccine status must undergo weekly COVID-19 testing and disclose weekly the results of those tests to the designated agency personnel.
This provision applies to all Executive Branch employees whether working remotely or in the office.
Special Instructions to Applicants
DMAS will only accept online applications/resumes submitted through the RMS by 11:59 p.m. on the referenced closing date.
In accordance with the DHRM Employment Equity Initiative adopted on July 1, 2019, State applications have been streamlined.
Applicants have the option to utilize their resume to provide detailed work history.
Consideration for an interview is based solely on the information within the application and/or resume.
Applicants requiring accommodation to apply for this position should contact the Agency receptionist for assistance.
ADA/EEO/AA
Name DMAS Talent Acquisition
Phone
Fax
Email askhcdtalentacq@dmas.virginia.gov