Job Description

The Georgia Department of Community Health (DCH) is currently seeking qualified applicants for the position of Review and Investigations Assistant Director, in the Office of Inspector General, Program Integrity Unit. The position provides critical support functions within the Program Integrity Unit and the Office of Inspector General, which helps safeguard the agency from fraud, waste, and abuse. The selected candidate will be responsible for managing the Review and Investigations subunit composed of 14 staff with three (3) direct reports to ensure that medical reviews of nursing homes, public health facilities, and community-based programs are conducted pursuant to state and federal regulations. The position will also work closely with the Director of Program Integrity to ensure that contractors provide services in compliance with contractual requirements. The Review and Investigations Assistant Director will also work closely with the Director of Program Integrity and Director of Managed Care Compliance to ensure oversight of program integrity activities identified in contracts for managed care organizations. In addition, the position will be responsible for preparing investigative reports for referral to the Medicaid Fraud Control Unit based on credible allegations of fraud pursuant to federal regulation. The selected candidate must be licensed in Georgia as a medical professional.

Essential duties and responsibilities:

The Review and Investigations Assistant Director shall perform the following duties and responsibilities:

• Serve as co-business owner for vendor contracts and ensure performance guarantees and deliverables are met, and payments are processed in accordance with contractual requirements.
• Coordinates with Divisions within the agency to effectively monitor Fraud, Waste, and Abuse.
• Oversees fraud referral process and refers cases to the Medicaid Fraud Control Unit based on credible allegations of fraud.
• Collaborate with contracted vendors, staff, and CMOs to ensure Medicaid providers are following Medicaid policies and procedures, state, and federal laws.
• Track and monitor managed care monthly and quarterly reports to ensure oversight of CMOs' Program Integrity activities identified in managed care contracts.
• Conducts or participates in the development, review, revision, interpretation, and/or implementation of policies, procedures, standards, and guidelines.
• Oversee the development and on-going management of one or more programs or projects consistent with agency goals and objectives.
• Participates in the planning, coordination, development and implementation of long-range goals and objectives.
• Coordinates on site visits at provider locations to facilitate utilization reviews.
• Effectively communicates with external and internal stakeholders at monthly meetings to mitigate fraud, waste, and abuse in the Georgia Medicaid program.
• Provides clinical expertise to DCH-OIG staff, contracted vendors, and managed care organizations to mitigate fraud, waste, and abuse related to utilization reviews.
• Leads special projects and participates in audits to ensure payment integrity of claims billed to the Medicaid program.
• Performs claims data analysis to identify aberrant billing trends for providers enrolled in the Medicaid program.

Nonessential functions: Performs all other duties assigned and/or delegates according to subordinate staff competencies.

MINIMUM QUALIFICATIONS:

Bachelor's degree in operations management, business administration, or a related field which includes five (5) years in a managerial or supervisory role; or nine (9) years of related professional experience which includes five (5) years in a managerial or supervisory role; or five (5) years of experience required at the lower-level Sr Mgr, Business Ops (GSM012) or position equivalent. Note: An equivalent combination of knowledge, education, job or intern experience, training, or certifications that provides the necessary knowledge and skills to successfully perform the job at the level listed may be substituted year-over year.

Preferred Qualifications:

Candidate must be an active licensed clinician in Georgia.

M.S. degree in Nursing, Psychology, Healthcare Administration, or similar clinical programs.

Certified Fraud Examiner or Accredited Health Care Fraud Examiner.

Experience with monitoring, investigations, case management, identifying and reviewing claims and auditing of government health care programs.

Experience in the preparation, review and delivery of formal medical/investigative reports including relevant statistical summaries and qualitative analysis of findings.

Knowledge of statistical data and reporting.

Knowledge of Georgia Medicaid and the MMIS System.

Knowledge of both Fee for Service and Managed Care Claims data.

Key Competencies:

Minimum of three years' experience conducting fraud, waste, and abuse reviews/investigations.

Minimum of two years supervisory experience.

Knowledge of Medicaid policies and procedures.

Minimum three years’ experience writing/reviewing fraud reports/investigations.

Experience in oversight of vendor contracts.

Experience working with Medicaid and/or Medicare claims.

Knowledge of and history of work with medical claims and data.

Proficient in Excel, Access, Data Analysis and Microsoft product.

Must possess excellent writing skills.

Ability to mentor and perform staff development to identify and address performance issues.

Ability to implement courses of actions to ensure compliance with federal and state regulations, and Medicaid policies and procedures.

Ability to analyze the operational impact of legislative and executive initiatives that impacts DCH-OIG and payment integrity of claims.

Ability to organize and manage program areas to mitigate fraud, waste, and abuse in the Medicaid program while protecting the payment integrity of claims.

Ability to set goals with defined milestones to measure progress to monitor key performance metrics.

Ability to counsel subordinates when necessary and develop performance improvement plans to address opportunities for improvement.

NOTE: This position is contingent on availability of federal funding through the Rural Health Transformation Program. Such federal funding is anticipated for a five-year period. Your employment may be terminated if such federal funding is reduced, lost or exhausted.

Additional Information

EARN MORE THAN A SALARY! In addition to a competitive salary, the Georgia Department of Community Health offers a generous benefits package, which includes employee retirement plan; paid holidays annually; vacation and sick leave; health, dental, vision, legal, disability, accidental death and dismemberment, health and childcare spending account.

Due to the volume of applications received, we are unable to provide information on application status by phone or e-mail. All qualified applicants will be considered but may not necessarily receive an interview. Selected applicants will be contacted by the hiring agency for next steps in the selection process. Applicants who are not selected will not receive notification.

THIS POSITION IS SUBJECT TO CLOSE AT ANY TIME ONCE A SATISFACTORY APPLICANT POOL HAS BEEN IDENTIFIED. APPLICATIONS WITHOUT WORK EXPERIENCE LISTED WILL NOT BE CONSIDERED. CURRENT GEORGIA STATE GOVERNMENT EMPLOYEES WILL BE SUBJECT TO STATE PERSONNEL BOARD (SPB) RULE PROVISIONS. THE POSITION MAY BE FILLED AT A LOWER OR HIGHER POSITION LEVEL.

This position is unclassified and employment is at-will. Candidates for this position maybe subject to a background history, reference check, and credit check.

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