Eligibility Unit Manager

Full job description Description and Functions Open Until Filled GENERAL DESCRIPTION:


This position is responsible for directing, managing, and coordinating all activities of: Medicaid Eligibility Quality Control, Payment Error Rate Measurement, Medicaid Eligibility Quality Assurance Monitoring, Investigations into suspected Medicaid Member Fraud, Waste, and Abuse, and confirming the Wyoming Medicaid and KidCare Childrens Health Insurance Program (CHIP) are administered in compliance with all federal and state eligibility rules, regulations, policies, and procedures.



Human Resource Contact: ESSENTIAL FUNCTIONS: The listed functions are illustrative only and are not intended to describe every function which may be performed at the job level.

Manages the MEQC program in adherence to guidance from the Centers for Medicare and Medicaid Services (CMS) and in accordance with Medicaid and KidCare CHIP regulations, rules, policies, and procedures. This requires activities such as reviewing federal guidance, developing and following universe and sampling plans, developing review criteria and forms, quality control of reviews and developing corrective action plans with other state staff. All of this must be completed within the timelines provided by CMS. Uses knowledge of Medicaid and KidCare CHIP to ensure benefits are determined accurately, timely, and consistently throughout the State. Compiles and analyzes data from reviews and prepares statistical and narrative reports and presentations specific to the activities and findings. Participates in administrative planning to advise and propose new tools to assist in review activities, system enhancements, outreach, or other issues that impact Medicaid and KidCare CHIP eligibility quality functions. Makes recommendations to the Eligibility and Client Services Administrator as needed, to ensure Medicaid and KidCare CHIP eligibility determinations are meeting the goals of the program. Participates in developing and monitoring Medicaid and KidCare CHIP eligibility quality control goals and performance measures. Provides information to the Eligibility and Client Services Section and KidCare CHIP staff when an eligibility error is identified. Manages the PERM program in adherence to guidance from the Centers for Medicare and Medicaid Services (CMS) and in accordance with Medicaid and KidCare CHIP regulations, rules, policies, and procedures. This includes the PERM MAGI pilots, test cases, and claims. This includes activities such as working with federal staff and contractors, working with state vendors, reviewing federal guidance, developing and following universe and sampling plans, developing review criteria and forms, quality control of reviews, entering test cases in a test environment, developing corrective action plans with other state staff, and providing recovery reports to fiscal staff. All activities must be completed within the timelines provided by CMS. Uses knowledge of Medicaid and KidCare CHIP to ensure benefits are determined accurately, timely, and consistently throughout the State. Compiles and analyzes data from reviews and prepares statistical and narrative reports and presentations specific to the activities and findings. Participates in administrative planning to advise and make recommendations to propose new tools to assist in review activities, system enhancements, outreach, or other issues that impact Medicaid and KidCare CHIP eligibility quality functions. Makes recommendations to the Eligibility and Client Services Administrator as needed, to confirm Medicaid and KidCare CHIP eligibility determinations are meeting the goals of the program. Participates in developing and monitoring Medicaid and KidCare CHIP eligibility quality control goals and performance measures. Provides information to the Eligibility and Client Services Section and KidCare CHIP staff when an eligibility error is identified. Manages the completion, assignment, and distribution of investigative casework to direct reports for the performance of initial vetting, preliminary, and full investigation activities of suspected Medicaid member fraud, waste, and abuse. Performs quality assurance review of direct report case summary reports. Compiles supporting case information and data into clear and concise summaries. Manages case information and drafts reports in accordance with Program Integrity Section policy and procedures. Makes recommendations for case outcomes to the Program Integrity Section Manager based on investigative findings. Collaborates with external partners: law enforcement, Attorney General staff, and County Attorneys when investigation findings confirm non-compliance. Provides testimony regarding investigation outcomes and findings at contested case hearings, and civil or criminal legal proceedings. Through the course of investigation activities, this position is also required to collaborate with other Wyoming Department of Health staff, Department of Family Services, Social Security Administration, and other state and federal partners. In addition to the supervisory activities related to member fraud investigations, this position is also responsible for performing preliminary and full investigations. Performing desk reviews and interviews of Wyoming Medicaid members to detect and mitigate suspected fraud, waste, and abuse of the Wyoming Medicaid Program. Performing data analysis and data organization to identify aberrant patterns of utilization of services through the use of tables, charts, graphs, and written reports. Request and review medical, financial, and other records to evaluate compliance with federal and state statutes, and all applicable policies, rules, and administrative regulations. Organize documentation and maintain case files; preserving the chain of custody by processing and documenting the sending and receipt of business documents for Program Integrity investigative activities.
Write preliminary, full investigation summaries, and final investigation reports. Confirms Medicaid and KidCare CHIP eligibility quality assurance monitoring activities are conducted timely to ensure accuracy and consistency of eligibility determinations made by the LTC Unit, the Customer Service Center, and the Tribal Eligibility staff. Uses knowledge of Medicaid programs and system reports to monitor caseloads and identify errors, patterns, or trends. Compiles and analyzes data from monitoring activities and prepares statistical and narrative reports and presentations specific to the activities and findings. Participates in administrative planning to advise and support continuous improvement efforts through the development of new monitoring tools, system enhancements, outreach, or other opportunities that impact Medicaid eligibility determination quality improvement outcomes. Makes recommendations to the Eligibility and Client Services Section, Eligibility and Client Services Section Administrator, the Senior Eligibility Manager, Vendor Contract Managers, and the Benefits Coordination Manager as needed, to confirm Medicaid eligibility determinations are meeting the goals of the program. Participates in developing and monitoring Medicaid eligibility quality assurance monitoring goals and performance measures. Provides information to the Eligibility and Client Services Section when an eligibility error is identified. Hires, trains and distributes work to Medicaid Eligibility Review Unit staff and assures new rules, regulations, and mandates are understood and implemented. Works with direct reports to create policies and procedures for the completion of Medicaid Eligibility Quality Control and Quality Monitoring activities. Prepares and delivers performance appraisal and quality assurance reviews of employees' work outputs. Works with direct reports on professional/personal development and communicates any disciplinary actions or issues. Establish goals and performance expectations for direct reports based on Department, Division, and Program Integrity Section strategic planning initiatives. Support the development and administration of training activities that are identified as needed from fraud, waste, and abuse detection activities. This will include training and education to Division staff that is intended to strengthen the administration of Medicaid programs and KidCare CHIP; as well as the provision of training and education to Medicaid clients. Participates in updating administrative rules, policies, procedures, and State Plan Amendments as needed to be in alignment with the Code of Federal Regulations (CFR). Coordinates with other WDH and State Agency staff on issues that may affect other programs. Qualifications PREFERENCES:


A BA/BS degree in a field of study that can be reasonably interpreted to perform tasks related to this position; 3-4 years of progressive experience in Medicaid and KidCare CHIP eligibility determinations; and 1-3 years of progressive work experience in quality assurance/compliance analysis and investigative techniques.

Preference will be given to candidates with…
…Any of the following: post-graduate education, current designation as a Certified Fraud Examiner (CFE) from the Association of Certified Fraud Examiners (ACFE), current designation as an Accredited Health Care Fraud Investigator (AHFI) from the National Health Care Anti-Fraud Association (NHCAA), or current designation as a Certified Welfare Fraud Investigator (CWFI) from the United Council on Welfare Fraud (UCOF).



KNOWLEDGE: Knowledge of healthcare delivery and regulatory systems, at both the State and Federal level, and integrated automated systems currently used by the Division of Healthcare Financing. Knowledge of medical terminology, medical diagnostic and procedural terms, and common medical payment procedural codes used in Current Procedural Terminology (CPT) and other nationally recognized coding references. Knowledge of Medicaid eligibility determination criteria for Medicaid State Plan, Waiver, and KidCare CHIP service categories. Knowledge of CMS regulations relating to MEQC, PERM, and other federally mandated/regulated oversight activities. Knowledge of court proceedings, testimony, and administrative appeals. Knowledge of state and federal government functions, state and federal statutes, rules, regulations, policies, and procedures governing Federal and State Medicaid and Medicare programs. Knowledge of Medicaid law and regulatory structure including State and Federal Medicaid statutes, regulations, and policies as outlined in the Code of Federal Regulations. Knowledge of fraud and abuse detection methods, and internal control systems. Knowledge of Wyoming personnel rules and skills in supervision. Skills in research and analysis of complex problems; identification of options and solutions; decision making and evaluation of results. Skills in public speaking, oral and written communication to varied audiences on complex and controversial issues. Ability to establish and maintain positive working relationships with individuals and groups. Ability to accept and be flexible with federal, state, and agency changes. Ability to balance multiple demands on time and resources. Ability to self-educate both formally and informally to remain current in areas of responsibility. Skill in operating computer equipment and software programs including Microsoft Excel, PowerPoint, SharePoint, Word, COGNOS Business Intelligence Tools, BMS, and case management systems. Skill in active listening, and creative problem-solving skills; strong oral, written, and interpersonal communication skills at a variety of levels and with multiple audiences. Skill in critical thinking, with an ability to evaluate complex sets of data and information to determine whether aberrancy, patterns, or discrepancies exist. Skill in establishing and maintaining effective working relationships with other program managers, providers, and the public. Ability to work independently with minimal supervision while balancing multiple demands on time and resources. Ability to make sound judgment calls, think quickly, and formulate concise answers and plans with known information while interpreting DHCF rules, policies, and procedures. Ability to analyze and comprehend complex Medicaid service utilization and eligibility data; identify patterns, trends, problems, and solutions; leverage deductive reasoning skills to form sound conclusions. Ability to draft concise reports utilizing technical writing tools and techniques. Experience demonstrating the ability to collect and organize information from complex data systems. Experience in decision-making and evaluation of results in order to make future program recommendations based on trends; Experience gathering and compiling data to meet Program Integrity user needs through the use of tables, charts, graphs, and written reports. Must be detail-oriented, highly organized, and self-motivated. Must maintain a high level of confidentiality both inside and outside of DHCF. MINIMUM QUALIFICATIONS : Education: Bachelor's Degree (typically in Human Services)
Experience: 1-2 years of progressive work experience (typically in Benefits and Eligibility) with acquired knowledge at the level of a Senior Quality Assurance Specialist
OR Education & Experience Substitution: 4-6 years of progressive work experience (typically in Benefits and Eligibility) with acquired knowledge at the level of a Senior Quality Assurance Specialist
Certificates, Licenses, Registrations: None


Necessary Special Requirements PHYSICAL WORKING CONDITIONS:
Typically, the employee may sit comfortably to perform the work; however, there may be some walking, standing, bending, carrying light items, driving an automobile, etc.
Special physical demands are not required to perform the work

NOTES: FLSA: Exempt The Wyoming Department of Health is an E-Verify employer. Supplemental Information
048-Wyoming Department of Health - Public Health Division


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Class Specifications are subject to change, please refer to the A & I HRD Website to ensure that you have the most recent version.
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