Job Specification Details

Planning, administrative, investigative, analytical, supervisory, and technical work involving all aspects of program integrity of the Department of Vermont Health Access (DVHA). Duties involve leading staff, other DVHA units, AHS Departments, Fiscal Agents, Pharmacy Benefit Managers, and eligibility and enrollment staff for both providers and 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 general direction of the SIU Director with extensive interaction with other internal and external partners.

The SIU Manager plans, coordinates, and directs all functions of the applicable team to detect, prevent and investigate fraud, waste, and abuse in the Vermont Medicaid program.  Strict adherence to all applicable CFRs, policy and procedures, State Plan, and federal and state regulations for staff, fiscal agents, providers, beneficiaries, and other departments as needed. Responsible to hire, onboard, train, lead and supervise personnel.

Adhere to Surveillance and Utilization Review (SUR) activities to monitor and analyze claims data of beneficiaries and providers. Review of Medicaid covered services received by beneficiaries to determine if beneficiary utilization and provider practices are appropriate and medically necessary.

SIU Manager designs, develops, and implements investigative and Standard Operating Procedures (SOP) for monitoring provider reviews, beneficiary eligibility, Public Assistance and Reporting Information System (PARIS), Medicaid Management Information System (MMIS) and the Pharmacy Benefits Manager (PBM) for aberrant patterns.

Review and guide auditors with preliminary reviews and full investigations and tracking of all financials related to settlements and recoupments. Prioritize activities by evaluating impact, state and federal regulations and risk to programs. When potential fraud cases are discovered, coordination with the Medicaid Fraud and Residential Abuse Unit and other law enforcement is required. SIU Manager may be required to attend depositions and testify in court.

Coordinates with SIU Director in preparation and response to all internal and external requests for federal and state surveys, reviews, and audits, and develops corrective action plans as necessary. Develops and/or evaluates instructional materials for staff, providers, and beneficiaries.

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

Oversee procedures, corrective action plans, terminations, appeals, and recoveries.

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 an office setting and in a variety of field situations. 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 service providers and management and the State Medicaid Authority.

Considerable knowledge of all program integrity activities and applicable CFRs, federal and state regulations and insurance programs.

Considerable knowledge of audit procedures

Knowledge of medical procedures and proper coding. 

Knowledge of data mining analytics.

Knowledge and skills in project management.

Knowledge and skills regarding clinical and medical necessity.

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 investigative and 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 35) or more years of experience in health care administration, public or business administration, a Medicaid program, or in benefits administration.
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.