MAPS2

MAPS 2

Full-time, Permanent

Olympia, WA

Who We Are:

The Health Care Authority (HCA) is Washington’s largest health care purchaser, responsible for providing comprehensive health coverage to more than 2 million residents through the Public Employees Benefits and Medicaid programs. The agency provides health purchasing leadership, benefiting both public and private sectors with a focus on moving the health delivery system away from volume toward higher value and better outcomes.

The Olympia office is located in downtown Olympia, within walking distance of shops, restaurants, bus lines, and less than one mile from the freeway.

Scope of Work:

Within the Section of Program Integrity (PI), the purpose of this position, Patient Review and Coordination (PRC) Program Manager, is to ensure Health Care Authority (HCA) is compliant with program integrity-related federal and state rules, regulations, and policies that govern Washington Apple Health programs. PI’s role is to conduct audits, reviews and analytics on HCA’s contracted providers and entities to identify, prevent and recover improper payments resulting from waste and abuse; and to refer potential fraud for investigation. Through these efforts the position supports HCA’s mission to “Provide high quality health care through innovative health policies and purchasing strategies.”

Some of the tasks this position will perform:

• Performs statewide reviews and analysis of client utilization patterns to determine placement in the PRC program;
• Develops, implements and provides direct consultation, care management and coordination with: clients, healthcare community providers, managed care plans, state and federal offices, divisions and administrations, and local law enforcement, to assure appropriate access to care for clients who are restricted in PRC;
• Participates and assists in preparation for client administrative hearings with HCA attorneys, and provides expert testimony during the administrative hearings; and
• Collaborates, recommends, promulgates and implements program policy and managed care contract changes to improve access to medical care for both fee-for-service and managed care clients.

Required Qualifications:

A Master’s Degree in Public Health, Public Administration or closely related field and two years supervisory or consultative experience in health or social services or Medicaid programs. Experience in health care related field. Experience conducting complex data analysis.

Two additional years of qualifying experience will substitute for the Master’s Degree provided a Bachelor’s degree has been achieved

OR

One year as a Medical Assistance Program Specialist 1

OR

Experience working in a Medicaid lock-in program such as PRC and five years of experience providing direct customer service and consultation in the areas of health insurance, community healthcare clinic or other setting, Medicaid or disability eligibility determinations, claims processing, or other customer service related field.

Preferred/Desired Qualifications:

• Expert knowledge of claims data processed through ProviderOne, Washington Apple Health programs, and related federal and state rules and regulations.
• Knowledge of data analysis methods, techniques and methodologies.
• Experience with client utilization, care coordination, and case management within the last five years.
• Experience in negotiating and coordinating settlement resolutions with managed care plans, medical directors, attorneys, healthcare providers and clients within the last five years.
• Ability to research and review documentation using critical thinking to determine if data and research substantiates a referral.
• Strong analytic skills involving the processing, analysis, interpretation and presentation of Medicaid claims data and other documentation and research.
• Problem solving skills involving a high degree of originality and independent judgment including the ability to identify critical issues and prepare recommendations for provider reviews, changes in procedures, WAC/billing instructions and/or systems in order to increase efficiencies and meet program integrity goals.
• Superior interpersonal skills, especially the ability to communicate, advocate, negotiate, listen and partner with a variety of individuals and groups internal and external to the program.
• Excellent written, oral and presentation skills utilizing Plain Talk principles.
• Computer skills including: Microsoft Excel, Microsoft Access, Microsoft Word, ACES, ProviderOne, PRISM, Barcode, FADS, SXC/Pharmacy Point of Sale, CARE, PRC database.

How to Apply:

Only candidates who reflect the minimum qualifications on their State application will be considered. Failure to follow the application instructions below may lead to disqualification. To apply for this position you will need to complete your profile and attach:

• A cover letter
• Current resume
• Three professional references

If you have questions about the process, or need reasonable accommodation, please contact the recruiter before the posting closes. The candidate pool certified for this recruitment may be used to fill future similar vacancies for up to the next six months.

Washington State is an equal opportunity employer. Persons with disabilities needing assistance in the application process, or those needing this job announcement in an alternative format may call the Human Resources Office at 360.725.0945 or email ryan.dahlstrom@hca.wa.gov .

*Persons under final consideration for initial appointment with HCA are subject to a background check*