Job description
This is position is located in Program Integrity , Richland County.
Are you the One? We are looking for a Program Coordinator II who detects, investigates, and identifies instances of suspected providers and recipient fraud or abuse of the Medicaid Program.
- Develop case reviews as determined to (1) Conduct unannounced onsite visits and obtain medical records, 2) Request medical records, 3) Send provider/recipient survey letters, 4) Send provider self-audit letters, 5) Request additional information or documentation, 6) Make telephone calls to recipients to verify services, 7) Coordinate and correspond case actions with Manage Care Organizations (referring providers timely should it be warranted), 8) Coordinate and correspond case and complaints with the investigator.
- Review all information received and conduct a comparison review between the Medicaid paid claims, applicable Medicaid rules and regulation and policy on all documentation or information obtained. Verify appropriateness and medical necessity of services billed to Medicaid. Determine if a fraud referral is warranted and coordinate with manager to complete a referral to the SC Medicaid Fraud Control Unit (SCMFCU) of the SC Attorney General's Office.
- Learn and use the current SAS Business Information Systems, Medicaid Management Information System (MMIS), etc. Be able to develop special reports in accordance with trends within the provider community. Set up and run Detail Claims Report (DCRs) and focused reports as needed in SAS. Be able to utilize SAS to identify aberrant billing of providers by researching the Fraud Frame Work. Conduct evaluation and analysis of provider statistical profiles and details claims report generated by SURS/SAS reporting system which is the first line review of data to include analysis and evaluation of exception criterial and profile reports as well as generate reports of paid claims data. Be able to research and triage alerts in SAS Fraud Frame Work.
- Evaluate paid claims history data and determine patterns of practice and adherence to Medicaid program policy and procedures. Research information and make decisions using requisite knowledge and expertise evaluating health delivery patterns of individual providers and specialties. Use appropriate methodology to conduct comparison studies, focus reviews, and random sampling, review universe of claims, self-audit, line by line sample or random sampling.
- Coordinate case actions with manager and program staff. Complete provider notifications of results/findings in letter. Identify and describe the provider's aberrant billing pattern/billing errors within the letter and on the Detailed Claims Report. Cite and include in the initial findings packet, the policy which validates the errors and make provider recommendations to prevent the improper billing from occurring in the future. Send educational letters as appropriate. Monitors case progression at 15-day and 35-day intervals and responds to providers as necessary.
- Coordinate or schedule prehearing and informal conferences with providers as necessary. Coordinate pre-hearing meetings with the pertinent agency staff. Document pre-hearing, informal conference and or appeal process. Coordinate case with the office of General Counseling as needed. Defend cases in Fair Hearing as scheduled.
- Health, Dental, Vision, Long Term Disability, and Life Insurance for Employee, Spouse, and Children.
- 15 days annual (vacation) leave per year.
- 15 days sick leave per year.
- 13 paid holidays.
- State Retirement Plan and Deferred Compensation Programs.
An equivalent combination of education and experience may be accepted with prior State Human Resources approval.
Preferred: A bachelor's degree and at least one (1) year of experience in health services or a related program area. Thorough knowledge of health care trends and practices.
Additional Requirements:
- Sitting or standing for long periods of time.
- Occasional overnight travel.
- Lifting requirements: 30 lbs.
- Overtime and/or weekend work with Deputy approval.
Please complete the State application to include all current and previous work history and education. A resume will not be accepted nor reviewed to determine if an applicant has met the qualifications for the position. Supplemental questions are considered part of your official application for qualification purposes. All applicants must apply online. All correspondence from the Office of Human Resources will be through electronic mail.
The South Carolina Department of Health and Human Services is committed to providing equal employment opportunities to all applicants and does not discriminate on the basis of race, color, religion, sex (including pregnancy, childbirth or related medical conditions, including, but not limited, to lactation), national origin, age (40 or older), disability or genetic information.
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