Job Specification Details

Planning, administrative, analytical, supervisory, and technical work involving all aspects of HealthCare programs compliance. Duties involve leading staff, other DVHA units, AHS Departments, Fiscal Agents, , and eligibility and enrollment staff for beneficiaries. Primary responsibility includes the adherence and compliance with all Code of Federal Regulations (CFR), to prevent, detect, and investigate fraud, waste, and abuse in the Medicaid program. Supervision is exercised over professional employees. Work is performed under the limited direction of the OMU Director with extensive interaction with other internal and external partners.

The DVHA Quality Control Unit focuses on identifying quality issues, based on adherence to approved processes and policies.  The DVHA OMU HCQC Unit Manager supervises the work of the DVHA HealthCare Quality Control Auditors to ensure conformance with state and federal regulations and the HCQC Standard Operating Procedures consistent with the Department of Vermont Health Access (DVHA) and the Agency of Human Services’ (AHS) mission, vision, and core values.    

The OMU HCQC Unit Manager plans, coordinates, and directs all functions of the HCQC team to detect, and prevent fraud, waste, and abuse in the Vermont Medicaid program by conducting case reviews (audits), internally and on behalf of CMS (MEQC Audit) Strict adherence to all CMS/MEQC Audit guidelines, CFRs, policy and procedures, State Plan, and federal and state regulations for eligibility staff, and beneficiaries. Responsible for hiring, onboard, train, lead and supervise personnel.

The OMU HCQC Unit Manager writes and implements MEQC planning documents, outlining the structure of how the QC unit will conduct the MEQC Federal Audit, prepares case-level and CAP reports to send to CMS. 

OMU HCQC Unit Manager designs, develops, and implements Standard Operating Procedures (SOP) for the HCQC Unit, as well as the HCQC Manual and job aids to identify any discrepancies in eligibility determinations that may lead to incorrect beneficiary benefits and prevent the misuse of Federal funds. 

Review and guide auditors with preliminary reviews and full desk case reviews and tracking of all financials related to financial payment reviews (under/overpayments). Prioritize activities by evaluating impact, state and federal regulations and risk to programs. 

Guides eligibility units in the development of corrective action plans by using the MEQC sub-regulatory guidance issued by CMS. . Develops and/or evaluates instructional materials used for staff when developing corrective action plans.

When potential fraud cases are discovered, a referral would be provided to SIU.

Preparation and presentation with OMU Director of all internal and external requests for regulators, auditors and DVHA leadership. federal and state surveys, reviews, and audits. 

Evaluate trends and establish identification, proactive and prevention metrics for the eligibility units.

Oversee procedures, corrective action plans, and financial payment reviews for return of Federal match when eligibility determination is incorrect.

Educate staff and provide training to others regarding compliance with CFRs, procedures, and state and federal regulations as necessary or required.

Consults with other DVHA and AHS staff as requested or necessary.

Performs related work as required.

All employees of the Agency of Human Services perform their respective functions adhering to four key practices: customer service, holistic service, strengths-based relationships, and results orientation.

Work is performed primarily in a home office setting. Some private means of transportation should be available since travel outside of the worksite will be required. Urgent deadlines can be anticipated. Position will have extensive interactions with eligibility units, management and the CMS/MEQC.

Considerable knowledge of all program integrity activities, specifically Medicaid auditing and the MEQC Federal Audit and applicable CFRs, federal and state regulations and insurance programs.

Considerable knowledge of audit procedures

Knowledge of Salesforce basic operations

Knowledge and skills in project management.

Ability to assess policies and procedures and recommend necessary and desirable modifications. 

Ability to manage assigned work responsibilities at an independent level and/or lead a team.

Ability to assess data and draw appropriate conclusions. 

Ability to prepare and present comprehensive analytical reports, both orally and written, and communicate effectively with staff and other internal and external partners. 

Ability to establish and maintain effective working relationships. 

Master's degree in public or business administration or in a human services or health field AND one (1) year or more of experience in health care administration, public or business administration, a Medicaid program or in benefits administration.

OR

Bachelor's degree AND three (3) or more years of experience in health care administration, public or business administration, a Medicaid program, or in benefits administration.

OR

Five (5) years or more of experience in health care administration, public or business administration, a Medicaid program, or in benefits administration.

Code of Federal Regulations (CFR), Utilization review, compliance, and regulatory oversight. Knowledge of the Vermont Medicaid program.

Candidates must pass any level of background investigation applicable to the position. In accordance with AHS Policy 4.02, Hiring Standards, Vermont and/or national criminal record checks, as well as DMV and adult and child abuse registry checks, as appropriate to the position under recruitment, will be conducted on candidates, with the exception of those who are current classified state employees seeking transfer, promotion or demotion into an AHS classified position or are persons exercising re-employment (RIF) rights.