Medical Assistance Program Specialist 3

Medical Assistance Program Specialist 3

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:

The Mission of the Division of Medicaid Program Operations and Integrity (MPOI) in the Health Care Authority (HCA) is to provide high quality administrative services to assist in the purchase and delivery of medical assistance program services to clients and members. MPOI works across the agency and in partnership with the health care community and community stakeholders to develop and manage high-quality, evidence-based health care programs and purchase services that enhance Medicaid clients’ ability to access appropriate, quality health care. Staff in the Division’s Compliance Review unit are responsible for federally required monitoring and oversight of the Washington Apple Health (Medicaid) managed care program, oversight and monitoring of new contracts (e.g., the Fully Integrated Managed Care Program and Apple Health Foster Care), manage and oversee the federally required External Quality Review (EQR) contract and related activities, provide clinical based technical assistance to Apple Health Managed Care Organizations (MCO), investigate and resolve enrollee access to care issues and quality of care concerns, monitor and improve special programs, including Third Party Liability (TPL), serve as Administrative hearing liaison and review and triage critical incidents reported by health plans.

The purpose of this subject matter expert position is directly linked to achieving three key agency goals: 1) Achieving the Triple Aim: better health, better care, lower cost; 2) access to quality care; and 3) excellent customer experience. The scope of this position is state wide: the Washington Apple Health Managed Care program provides health care services to over 1.6 million Washington residents including low income, disabled children and adults.

The purpose of this Medical Assistance Program Specialist 3 (MAPS 3) is to participate in the Compliance Review unit’s monitoring activities for Apple Health managed care programs. The work of this position is directly linked to the agency Vision: a Healthier Washington.

Some of the tasks this position will perform:

Conduct monitoring activities of MCO pharmacy programs in coordination with MCRA Section monitoring efforts.

• Develop and revise documentation tools, guidelines, checklists, and report formats with which to monitor MCO pharmacy related processes and outputs.
• Develop process for regular review of MCO pharmacy related adverse benefit determinations (denials) and appeals.
• Use pharmacy knowledge and expertise to perform desk audits of MCO pharmacy programs as part of federally required managed care monitoring and oversight activities.
• Document strengths, opportunities, and findings resulting from documentation and file review in a standardized report format.
• Communicate review findings (both positive and negative) to MCOs verbally and in writing through oral interviews and formal written reports.
• Develop corrective action for MCOs in all necessary areas; review corrective action plans submitted by MCOs for completion.
• Provide technical assistance to MCOs.

Review pharmacy related enrollee materials developed and used by MCOs

Tasks include:

• Use pharmacy knowledge and expertise to review MCO pharmacy related enrollee materials.
• Use professional judgment to approve materials, or not approve them, and recommend changes the MCO must make before resubmitting documents to HCA.
• Provide technical assistance to MCOs.

Assist in the investigation and resolution of MCO pharmacy related grievances.

• Use pharmacy knowledge and expertise to assist managed care contract managers to resolve grievances by enrollees or others on behalf of an enrollee experiencing difficulty or delay in accessing pharmacy related services in managed care.
• Assist in the investigation of concern/complaint and development of a resolution with the enrollee and the MCO.
  

Required Qualifications:

A Bachelor’s degree from an accredited college with a major study in public health, public administration, business administration, social work or closely related field and three years supervisory or consultative experience in health services, social service, Medicaid or social security disability programs.

OR

One year as a MAPS 2

OR

Two additional years of qualifying experience administering benefits within the Covered Outpatient Drug program of a state Medicaid agency including development and promulgation of operational policies will substitute for the required Bachelor’s degree.

Preferred/Desired Qualifications:

At least five years’ experience administering benefits in a Medicaid Covered Outpatient Drug program or direction operations for a Pharmacy benefits Manager in the commercial insurance agency.

Required Competencies (knowledge, skills, abilities and behaviors):

Must have experience in or a working knowledge of:

• State and federal managed care and related laws (e.g., HIPAA), policies, regulations and procedures on Medicaid and healthcare both within and outside HCA;
• State and federal laws, policies, regulations, and procedures related to the delivery of prescription drug benefits under Medicaid;
• Managed care operations, delivery systems, customer service activities, and policy issues;
• State and federal laws regarding the practice of pharmacy;
• Federal rules regulating Medicaid pharmacy requirements;
• Fee-for-service Prior Authorization requirements for pharmacy ;
• Medical necessity criteria and applicability to pharmaceutical coverage;
• Reviewing data and reports to assess pharmacy program efficacy
• Pharmacy Benefits Managers
• Contract terms and processes.

Project management, including team facilitation and process improvement methods.

• HCA and DSHS structure and function of the various sub-divisions of the agencies, including relevant medical health and mental health policies, procedures, programs and services to ensure the delivery of quality and integrated health care;
• Facilitating large meetings and task forces with state and local participants.
• Data management.
• General knowledge of operation and data elements of ProviderOne’s claim processing system, operational data store, and adhoc data warehouse;
• General knowledge of querying data using Cognos or other decision support systems and/or fraud/abuse detection systems.
• Computer software literacy.

Skills:

• Excellent verbal and written communication skills, including technical and non-technical report writing and oral presentations with a wide variety of audiences including community members, provider groups, clients and client advocates;
• Critical thinking skills

Ability to:

• Facilitate timely communications and interchange between diverse groups of internal and external departments, agencies and the public.
• Work effectively with other HCA staff, providers and managed care plan staff to analyze and resolve complex problems related to managed care programs.
• Independently manage competing timelines to meet critical deadlines, and handle multiple projects at a time.
• Collaborate across systems, build teams and work cooperatively with internal and external resources for successful program management and development.
• Analyze data related to contract performance and other issues relating to the managed care contracts;
• Public relations and customer service skills, including conflict resolution and negotiating techniques.
• Strategic planning.
• Research abilities.

Behaviors:

• Maintain the highest standards of personal/professional and ethical conduct
• Model behaviors that encourage an open, inclusive work environment
• Share appropriate information internally and externally

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*