Program Coodinator II (Provider Network Analyst) / 61047841

The Agency’s mission is to be boldly innovative in improving the health and quality of life for South Carolinians. This is position is located in the Bureau of Managed Care, Richland County. This is an in-office role and not a telecommute or remote position. Are you the One? We are looking for a Program Coordinator II (Provider Network Analyst) who will serve as the Medicaid Provider Network Analyst for the South Carolina Department of Health and Human Services in the Bureau of Managed Care. Acts as the lead analyst and performs independent, complex work providing coordination of managed care plan provider network activities within the Bureau of Managed Care. This work consists of reviewing administrative policies, procedures, guidelines, and related directives impacting managed care plan contract compliance issues and problems; interpreting network analysis results and identifying areas of opportunity; and recommending appropriate action.

• Develops and implements solutions and improvements related to provider networks as part of an interdisciplinary team. Consults with team members to ensure solutions are compliant with federal regulations, statutes, administrative rules, South Carolina State Medicaid State Plan, contract requirements, and Medicaid policies and procedures. Investigates, assesses, analyzes compliance, and makes recommendations to resolve issues and problems identified in managed care plan provider network activities. Provides direction to SCDHHS contract monitors for assigned managed care plans, Plan Management leadership, and their staff to address non-compliance issues related to provider network activities.
• Coordinates and participates in meetings within the Agency, managed care organizations, and other stakeholders. Prepares and delivers presentations to managed care organizations and other stakeholders. Represents SCDHHS on health care related committees, task forces, and special projects as assigned. Participates in meetings, conferences, and workshops on federal and state health care related programs and managed care programs. Participates in strategic planning activities to improve access and quality of care, and increase the efficiency and cost-effectiveness of the Medicaid programs.
• Conducts program training and provides technical assistance related to Medicaid managed care programs, compliance with contract provisions, including provider network requirements, to ensure consistency in program operation and conformity with goals and objectives of the Agency, state and federal laws, rules, regulations and guidelines. Works MCOs to identify and resolve network challenges impacting individual members with unique circumstances.
• Performs program monitoring and network analysis activities to determine managed care plan compliance, including: analyzing provider network reports for managed care plans, coordinating and conducting “secret shopper” activities, conducting in-depth follow-up investigation and assessment of managed care plans’ provider network activities, maintaining records, preparing reports, and correspondence with managed care plans. Assists in the completion of programmatic reports of secret shopper and other activities for improvement and resolution of provider network compliance as required.
• Proposes and maintains requirements for managed care plan provider network reports/outputs to be used for compliance with contract standards. Identifies potential changes to requirements and recommends changes to technical staff in accordance with established procedures. Provides feedback to Fee for Service program area for potential provider recruitment to expand options for Managed Care plan network gaps.

• Under the supervision of the Director of Targeted Oversight, utilizes federal and state regulations, the Agency’s strategic plan, the Managed Care Contract, Managed Care Policy and Procedures, and the Managed Care Report Companion Guide to develop specific deliverables to be monitored by the targeted oversight staff. Works with the Managed Care Contract Writer, legal department, and other SCDHHS stakeholders to ensure the Managed Care Contract, Managed Care Policy and Procedures, and Managed Care Report Companion Guide remain current to meet requirements and further the work of SCDHHS as related to this position.

• Serves as a point of contact for internal agency stakeholders and external contractors and vendors. Conducts formal and informal communications through the course of contract administration and management. Administers contract monitoring program to ensures performance conforms to contract requirements in terms of quality, quantity, timeliness, and cost as these terms are defined within the contracts and to agency satisfaction in accordance with established policies. Identifies, researches, and resolves contractual issues and disputes by developing and implementing a plan of action, tracking plan progress, and adjusting course where necessary to facilitate a mutually agreeable resolution. Addresses contractor deficiencies. Assists with contract and RFP creation and negotiations. Facilitates Contract Change Orders, Amendments, and Renewal documents. Ensures significant events are well-documented and records of monitoring results are maintained, to include all correspondence, amendments, and meetings. Thoroughly documents vendor performance standards that do not meet the contractual requirements. Reviews invoices and verifies contractors have demonstrated satisfactory delivery of services as agreed to in the contract and approves payment if deemed satisfactory. Tracks spend as defined through awarded Contract, Purchase Order, and Contractor Invoices; ensures compliance with the contract terms; identifies and reduces fiscal or program risk.

• Maintains up-to-date knowledge concerning the South Carolina Medicaid program, including pertinent federal regulations, state statutes, administrative rules, South Carolina Medicaid State Plan, and Medicaid program manuals. Remains informed about managed care contracts, Medicaid systems and technology, and South Carolina Medicaid provider network guidelines. Leads or supports other projects proactively or as assigned by Agency leadership. Continuously engages in process improvement to support Agency, Division, and Bureau-wide strategies, objectives, and initiatives. Collaborates with other managed care team members in research, development, implementation, and evaluation activities for services, projects, and agency initiatives as assigned. Performs other related duties as required to include travel.

A bachelor’s degree in a health, administration, or data management/analysis field and at least three (3) years of relevant professional experience in social service programs, business administration, general administrative management; OR

A master’s degree in health, administration, or data management/analysis field and at least one (1) year of relevant professional experience in social service programs, business administration, general administrative management.

Preferred: Current enrollment in a Master’s Degree program in a health, administration, or data management/analysis field with two (2) or more of the following; relevant internship, case competition, fellowship, research, projects or the like in lieu of one (1) year of work experience.

Additional Requirements:

• Occasional overnight travel.
• Overtime and/or weekend work with Deputy approval.
• Sitting or standing for long periods of time.
• Lifting requirements: 10 lbs.
• Valid driver’s license.
• In-office role., * Experience and knowledge of Grant/Contract Management or Administration preferred.
• Knowledge and understanding of healthcare systems design and operations.
• Knowledge of provider types and specialties preferred.
• Knowledge of Medicaid Program and Managed Care or health insurance preferred.
• Ability to work cooperatively as a member of the team.
• Ability to understand and apply applicable statutes, rules, regulations, policies, and procedures.
• Ability to determine work priorities and ensure proper completion of work assignments in a timely manner.
• Knowledge of methods necessary for efficient compiling, organizing, and analyzing data.
• Ability to collect, analyze, and evaluate data quickly, develop reports, and make recommendations.
• Knowledge of, and experience with, word processing, spreadsheet and/or database software.
• Knowledge and understanding of GIS networks.
• Ability to communicate effectively, both verbally and in writing.
• Rudimentary understanding of SAS or other programming language preferred but not required.

The South Carolina Department of Health and Human Services offers an exceptional benefits package for FTE and TGE positions that includes:

• 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.