Search for More Jobs
Forward this job to a friend
Apply by email without Registering
Apply by creating/using account
Please enter your registered email address, and we'll email you a link to reset your password right away.
Job Description: SCOPE OF THE PROJECT:
The Fee for Service Operations Director is responsible for a broad range of the operational activities that includes payment services, provider enrollment and management. Oversees both department staff and major contracts for delivering these services. Identifies and articulates root cause and predictive analysis of policy and procedural changes of ongoing Fee for Service Operations. Recommends and oversees implementation of program improvement initiatives, including establishment of key performance indicators (KPIs) to assess business unit performance over time.
Under general supervision, manages, monitors and coordinates all tasks associated within the Fee for Service Operations. This includes managing costs, schedule, scope, and quality of all activities and deliverables on project. Responsible for developing, operating, and incrementally improving a catalog of services related to all operations functions within SCDHHS. The articulation of these services shall adhere to the Medicaid Information Technology Architecture (MITA) 3.0 business architecture.
DAILY DUTIES / RESPONSIBILITIES:
Within defined deadlines, candidate will provide functional services to include:
• Performs fundamental supervisory and leadership functions in accordance with Department policies and procedures, best practices and Federal and State rules and regulations, especially with regard to Equal Employment Opportunity Commission (EEOC) standards. Maintains an effective organizational team and motivates diverse staff to accomplish mission critical operations and objectives. Promotes workforce engagement.
• Directs the Fee for Service Operations supporting the agency's fee for service claims processing, provide customer service, and provider enrollment and management functions. Includes the design, implementations, and management of processes procedures, and governance to achieve and maintain efficient and effective Provider Services. Responsible for establishing, tracking, and reporting on Provider Services performance metrics, and using these metrics to operate a continue services improvement effort. Coordinate provider services activity with other departmental business units, include health and program policy, project management, new health initiatives, and external contractors. Serves as a Provider Services subject matter and technical expert to agency and external stakeholders.
• Responsible for review and assessment of all Fee for service Operations business units for potential program improvement intervention, business unit reorganization, and introduction of KPIs to monitor program performance. Responsible for performing agency-wide analysis to determine which existing business units belong in single, coherent Fee for service Operations organization and which belong in other verticals. Also responsible for identifying new business units necessary for efficient and effective Fee for service operations management which may include establishment of new integration within the agency, securing vendors to perform business operations, or a combination thereof.. Provides analysis, design, and oversight for integration of existing programs into agency operations.
• Responsible for establishing a reporting and analytics service for Fee for Service Operations, including KPI and performance dashboards, root cause analysis, and other reporting to improve operational awareness for all relevant business units. Will work in conjunction with the Office of Information management (OIM) Enterprise Services unit to define and establish data and reporting services necessary to complete this effort. Will work in conjunction with OIM Project management office (PMO) to align program KPIs to the Information Technology Infrastructure Library (ITIL) Version 3.0.
• Responsible for supporting the articulation and design of common workflow processes (e.g. member, provider, claims, finance, and prior authorization/qio) associated with the Replacement MMIS program. Serve as business owner for Provider Operations, including Provider Enrollment, Claims Operations, and related reference and service authorization operations, and participate in common-process design efforts; manage the participation of Provider Operations subject matter experts (SMEs) in the RMMIS workgroup process. Will work in conjunction with RMMIS program leadership and other program business owners to support adequate completion of RMMIS workflow effort.
REQUIRED SKILLS (RANK IN ORDER OF IMPORTANCE):
• Demonstrates sound supervisory skills with efforts to promote equal opportunity
• Proficient in Word, Excel and PowerPoint
• Capable of analyzing and interpreting complex financial data in the application of budgetary policies and procedures.
• Ability to plan, organize, prioritize and coordinate work assignments.
• Ability to manage work, delegate and provide guidance to employees
• Ability to make presentations and prepare reports
• Ability to assign appropriate priorities to work activities based on organizational goals and situational pressures
• Ability to conceptualize needed change and to initiate appropriate activities to move from concepts to implementation
• Ability to interpret and apply rules and regulations
• Ability to establish and maintain effective working relationships
• Ability to exercise judgement and discretion
PREFERRED SKILLS (RANK IN ORDER OF IMPORTANCE):
• Direct experience leading Medicaid and/or human services bureaucracy teams/organizations through signification process design and improvements.
• Exceptional project management skills including the ability to manage multiple projects in a cross-functional environment.
• Expertise in budget planning, financial management, and resource management
• Ability to communicate effectively, in both written and oral forms and to articulate complex technology and operations solutions in business terms.
• Experience with commercial and/or public health payor systems, Medicaid Management Information Systems (MMIS), medical claims processing, provider network management and engagement, and the federal and SC rules & regulations governing public health policy and service delivery.
• Experience managing operations service units
• Experience with designing, managing, and incrementally improving service units to optimize performance.
• Experience in health insurance or health service delivery environments (i.e. public sector health – Medicaid, Medicare, Tricare )
• Demonstrate extreme focus on translating strategy into action and achieving measurable results in a dynamic environment
• Advanced management skills.
Bachelor's degree and relevant program experience. All degrees must be from a college or higher education institution recognized by the US Department of Education & Council for Higher Education (CHEA).
Bill Rate up to $
Statement of Work (SOW) for Contingent Labor Request
Apply by creating/using account