Location: Baton Rouge,LA, USA
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Department
Compliance Operations
Job Summary
Job Description
* Acts as the lead of the Chisolm notice review process.
* Executes the approval and denial determination process appropriately and per guidelines/regulations.
* Efficiently monitors and tracks the review process.
* Creates and reviews internal reports to ensure all monitoring activities remain on schedule and are completed within the required timelines; submits to Chisolm compliance officer for review.
* Assist in researching, and developing Applied Behavior Analysis (ABA) policies.
* Assist the Chisholm compliance office in tracking and fielding ABA issues from both providers and members.
* Assist the Chisolm compliance officer in monitoring the Medicaid managed care organizations (MCOs) and the Medicaid fiscal intermediary for compliance with all Chisolm orders and stipulations.
* Analyzes each prior authorization (PA) to ensure that the notice meets all Chisholm requirements and communicates any issues with that notice to the MCO, Medicaid's fiscal intermediary and the internal Chisholm compliance officer.
* If a request is denied:
* Determines if it should have gone to the internal (Medicaid) prior authorization liaison (PAL).
* Determines if the PA went to the internal PAL.
* Determines if the PAL process was properly followed.
* Coordinates with the Louisiana Department of Health (LDH) EPSDT PCS and home health manager to determine if policy was appropriately applied when denying services.
* Determines if the case was Chronic Needs.
* Determines if the member was previously approved to receive the service by the Medicaid fiscal intermediary or another MCO.
* Determines if the member was previously approved for the service and if so was there a change in condition.
* Documents all of the above and forwards to the program manager for review and approval before communicating issues to the MCO or the Medicaid fiscal intermediary.
* Conducts random reviews of the MCO external PAL (PAL that tracks and receives PAL referrals from support coordinators).
* Acts as Chisolm training subject matter expert
* Identifies training opportunities with internal and external stakeholders.
* Develops and manages training content of department educational materials, including Chisolm guides and staff manuals.
* Supports Chisolm compliance officer in delivery of trainings, as needed.
* Assists Chisolm compliance officer in training of new staff.
* Plans and coordinates Chisholm compliance meetings with MCOs and providers for Chisholm and ABA related issues.
* Assists the Chisolm Compliance Officer with researching and resolving compliance issues by researching and reviewing Chisolm orders and stipulations.
* Assists in organizing and reviewing LDH responses to requests from Plaintiffs' Counsel.
* Compiles performance indicators quarterly report; submits to supervisor for review and dissemination.
* Develops, tracks and maintains various electronic tracking systems.
* Conducts and participates in meetings, workgroups, public meetings, and other activities as directed.
* Receives and fulfills special request or projects as assigned by supervisor.
* Reviews and recommends revisions to processes for efficiency and efficacy.
* Collaborates with LDH staff, other programs and state agencies, on items related to development, planning and implementation of Chisolm compliance.
* Other tasks and non-complex projects as directed.
QUALIFICATIONS
REQUIRED:
* Bachelor's degree or 6 years of professional work experience in lieu of degree.
* Minimum 1 year of professional experience working with federal/state healthcare programs.
* Working knowledge of Microsoft Suite and Zoom.
* Excellent analytical skills, effective organizational and time management skills.
* Great attention to detail and follow up, and verbal/written communications skills.
* Able to set, follow, and meet scheduled deadlines.
DESIRED:
* Advanced degree.
* Minimum 2 years of EPSDT PCS, legal/paralegal, or home health background/experience.
* Minimum 2 years of professional experience with federal/state health care programs.
* Minimum 2 years pf professional experience with compliance and/or project management activity.
* Minimum 1 year professional experience in editing documents based on court orders/legal stipulation/legislation.
* Relevant industry related certifications.
Required Attachments
Please upload the following documents in the Resume/Cover Letter section.
* Detailed resume listing relevant qualifications and experience;
* Cover Letter indicating why you are a good fit for the position and University of Louisiana Systems;
* Names and contact information of three references;
* Diversity Statement (required for all Faculty positions and any Staff position of Assistant Manager and higher).
See Diversity Statement instructions by clicking this link:
Applications that do not include the required uploaded documents may not be considered.
Posting Close Date
This position will remain open until filled.
Note to Applicant:
Applicants should fully describe their qualifications and experience with specific reference to each of the minimum and preferred qualifications in their cover letter. The search committee will use this information during the initial review of application materials.
References will be contacted at the appropriate phase of the recruitment process.
This position may require a criminal background check to be conducted on the candidate(s) selected for hire.
As part of the hiring process, applicants for positions at the University of New Orleans may be required to demonstrate the ability to perform job-related tasks.
The University of New Orleans is an Affirmative Action and Equal Employment Opportunity employer. We do not discriminate on the basis of race, gender, color, religion, national origin, disability, sexual orientation, gender identity, protected Veteran status, age if 40 or older, or any other characteristic protected by federal, state, or local law.