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   Current UPMC employees must apply in HR Direct

Administrator, Medicaid Compliance

Description

UPMC Community Health Choices is seeking an Administrator, Medicaid Compliance!

The Administrator, Medicaid Compliance reports to the Sr. Director, Medicaid & MLTSS Compliance. This position strategically ensures compliance with all relevant and applicable Medicaid and MLTSS laws, regulations, contractual agreements, standards and requirements in a manner that continually supports the business and operational areas.

During COVID-19, this role is remote. When work returns to normal, there will be an option to remain home or work in the office. 

Responsibilities:
• Assists in the development of clear, effective, and timely reports and updates for senior management and/or the Board regarding Medicaid and CHC Compliance Program effectiveness, initiatives and issues, including all relevant metrics, dashboards, and information
• Develops, assesses, and adapts clear and effective Medicaid and CHC Compliance policies, procedures, training, communications and awareness materials, controls, and initiatives to ensure clear and consistent understanding and practices throughout internal operations
• Develops, assesses, and adapts clear and effective remediation and corrective action initiatives, protocols, and controls to ensure proper and timely compliance
• Effectively lives, models, communicates, and supports the values of UPMC and performs in accordance with UPMC system-wide competencies and behaviors
• Ensures strategic and operational partnership and collaboration with the business, operational, and additional compliance areas to leverage cross-departmental synergies and efficiencies
• Keeps abreast of changing industry requirements and regulations, including all relevant laws, industry standards, and company practices and initiatives
• Strategically works to ensure compliance with all relevant and applicable Medicaid and CHC/MLTSS laws, DHS and CMS regulations, and DHS contractual requirements and standards in a manner that continually supports the business and operational areas
• Works with Senior Director, Manager, and Senior Administrator(s) to complete ongoing and regular gap analyses, risk assessments, and program effectiveness assessments for the Medicaid and CHC Compliance Programs
• Works with Senior Director, Manager, and Senior Administrator(s) to conduct annual and ongoing Medicaid and CHC compliance training to UPMC ISD staff and applicable parties
• Ensures timely and appropriate notification and escalation to Senior Administrator, Manager, and/or Senior Director (as appropriate) of concerns, issues, or questions and works to support internal management team in addressing and resolving as needed
• Partners closely with assigned functional areas to ensure appropriate and effective compliance oversight is being conducted, including open discussion of compliance and operational concerns, review of key performance indicators as appropriate, review of DHS operational reports as appropriate, etc.
• Assists Manager with Medicaid Compliance Committee and CHC Compliance Committee preparation as needed, including updated key performance indicators, DHS reporting, and compliance-related topics of discussion
• Provides Manager with timely working draft of monthly Compliance updates related to Administrator’s assigned functional areas with minimal supervision and corrections
• Understands the Pennsylvania HealthChoices and Community HealthChoices agreements in good detail, particularly those sections pertaining to Administrator’s assigned functional areas
• Ensures timely communication and training of key department personnel impacted by new or changed contractual or other compliance requirements
• In collaboration with appropriate health plan departments and internal staff, including Compliance Senior Administrator(s), Manager, and Senior Director, develops and monitors implementation of corrective action plans to improve performance when necessary
• Works collaboratively with staff dedicated to the Medicaid and HealthChoices programs from other UPMC departments to ensure effective program compliance and integration
• Assist and support Senior Director in efforts to build, sustain, and expand (as needed) a cohesive and stable Compliance program
• Assist and support Senior Director in creating and maintaining positive trend of staff culture and employee engagement while growing Medicaid and CHC Compliance teams with minimal staff turnover
• In collaboration with appropriate health plan departments and staff, develop and monitor implementation of corrective action plans to improve performance when necessary
• Perform ongoing analysis of client business problems, participate in identifying solutions, and ensure that the appropriate resolution occurs
• Maintain Senior Director (and/or Manager/Senior Administrator(s)) apprised of relevant issues, questions, and/or concerns related to your assigned functional area. If necessary, Administrator should schedule additional time with Sr Director (and/or others if needed) to discuss issues in greater detail to ensure internal alignment and formulate any needed action plans

Qualifications

  • Bachelor's degree required. Relevant graduate degree (e.g. Master's degree in a related field or Juris Doctor) preferred.
  • Five years of compliance experience, Medicaid and/or CHC/MLTSS experience, and/or legal experience, preferably on the insurance (payer) side preferred.
  • Pennsylvania-specific Medicaid and/or MLTSS experience preferred.
  • Prior in-house legal or compliance experience strongly preferred.
  • Successful experience in designing and building highly effective relevant compliance programs from scratch and/or significantly enhancing such programs strongly preferred.
  • Strong subject matter expertise and knowledge of all relevant Medicaid and LTSS laws, regulations, contractual requirements, industry standards and best practices required.
  • Strong acumen and understanding of healthcare, health insurance and managed health care industries and organizations required. 
  • Excellent oral, listening and written communication skills. 
  • Strong project management skills and experience required, particularly as it relates to managing and leading across large and matrixed organizations.
  • Must have strong analytical and organizational skills as well as problem-solving capabilities to ensure that business plans and strategies do not subject the organization to legal, regulatory or contractual violations and/or undue risk or exposure.
  • Strong partnership-, relationship-, consensus- and coalition-building skills required. Strong emotional intelligence and self-awareness required. 
  • Strong executive polish and presence required. 
  • The role requires a leader who strikes the optimal balance between strategically navigating the compliance requirements and business needs in a manner that's nuanced and mutually reinforcing.
  • Strong strategic, business, operational and leadership mindset and skills required. Highly consultative and partnership-oriented in approach.
  • Strong and reliable judgment and discretion required. 


Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct