Provider Operations MC Oversight Consultant
DataStaff, Inc is seeking a Provider Operations MC Oversight Consultant for a long-term contract opportunity with one of our direct clients located in Raleigh, NC
*This role is hybrid; 1 day per week will be on-site
Job Description:
Provider Operations assumes responsibility for an extensive amount of oversight and structured monitoring activities of the Fiscal Agent and the Managed Care health plans (SPs/TPs/PIHPs/CFSP/CCNC/TOE).
Responsibilities:
- Perform assignments to support the implementation and operations of the NC Medicaid Managed Care (MC) to include Standard Plan (SP), Behavioral Health Intellectual/Developmental Disabilities Tailored Plan (TP), Prepaid Inpatient Health Plan Medicaid Direct (PIHP), Children and Families Specialty Plan (CFSP), Eastern Band of Cherokee Indians (EBCI) Tribal Option Entity (TOE), Community Care of North Carolina (CCNC), and future managed care programs.
- Respond to Inbound questions from providers, contractors, or other interested parties related to the managed care, utilizing information from the contract, policy papers, and other existing resources.
- Serve as an MC Program Liaison to include attending meetings, workgroup sessions, and staying abreast of operational developments for current managed care programs, as well as assist with the implementation of future managed care programs.
- Assist with the development, review, and revision of internal business procedures to outline how Provider Operations will ensure compliance with established contractual and specific program requirements.
- Work cross-functionally within Provider Ops and with other Business Units (BUs) and Divisions with implementation and readiness activities before MC launch, and with oversight and monitoring activities once operational.
- Review inbound materials and documents submitted by vendors to determine compliance with requirements set forth by the Department.
- Timely completion of assigned monitoring activities by following written/verbal instructions as part of the Department’s oversight responsibilities.
- Other duties as assigned to meet Provider Operations’ goals and needs.
Knowledge, Abilities and Skills:
- Ability to establish and maintain effective working relationships with internal and external partners, administrative officials, and the public.
- Ability to express oneself clearly and concisely in oral and written form.
- Proven ability to interpret and apply complex Federal and State regulations and requirements.
- Demonstrated strong proficiency in Microsoft Excel, Outlook, Teams, Word, PowerPoint, and SharePoint.
- Demonstrated understanding of public or private health care delivery systems.
- Experience in collecting and analyzing healthcare data and information.
- Ability to identify opportunities for process improvements and perform in a manner that mitigates risk.
- Ability to pay close attention to details and meet deadlines.
Expectations in the form of Goals and Tasks:
- Participate in monitoring activities and oversight of vendors/partners/subcontractors.
- Participate in, and assist with, when necessary, trainings related to managed care and Provider Operations.
- Address contractual non-compliance with vendors/partners/subcontractors and participate in subsequent meetings with the MC Oversight team, Legal, and other BUs to follow the process through. To include opening and following Command Case tickets in ServiceNow and in NCMT Help Center meetings and subsequent necessary steps.
- Be a liaison with communications, emails, meetings, operational reports, and deliverables for assigned MC plans.
- Review, revise, and develop business procedures for Provider Operations.
- Participate in all relevant meetings as determined by the SOW and management.
- Review inbound deliverables as primary and secondary reviewers platform (PCDU).
- Review and approve operational reports, as assigned, to complete monitoring activities.
- Mentoring and assisting other staff members with managed care duties.
This opportunity is available as a W2 position with a competitive benefits package. DataStaff, Inc. offers medical, dental, and vision coverage options as well as paid vacation, sick, and holiday leave. As many of our opportunities are long-term, we also have a 401k program available for employees after 6 months.