Description of Work/Duties:

Consultant will work with the Department of Human Services, Office of Medical Assistance Programs (Department).

Consultant will:

• Be available as a consultant on average 37.5 hours per week;
• Possess a documented work history of two r more years of experience performing provider relations/network management and administration within the previous five years;
• Possess basic computer skills, including familiarity with Microsoft Office programs.
• Consultant will provide managerial leadership and oversight to project and processes for the Office of Medical Assistance.
• Consultant will be assigned to represent the OMAP on management workgroups and project teams.
• Assignments will consist of a combination of on-going process responsibilities, standing work group participation and time-limited projects related to the management and operations of all aspects of the Pennsylvania Medicaid program, including but not limited to:
• Develop utilization specific reporting to identify access patterns, practice styles, accessibility, and configuration of medical services;
• Design and implementation of a proactive Provider Relations process, including provider education and network development;
• Evaluation and implementation of system enhancements for service delivery (including development of RFPs), provider enrollment, provider inquiry, and medical review;
• Analysis of pharmaceutical programs and outcomes impacts;
• Evaluation of currents processes and implementation of recommended process improvements;
• Consult with senior staff within OMAP to outline major operational issues and develop resolutions based on sound data analysis;
• Act as liaison between the Department and external stakeholders (individuals and/or groups);
• Assist in the development of in-house training programs, medically necessary criteria, and quality of care indicators; and
• Assist in determining if any changes should be made to criteria or regulations to better serve their clients.
• Consultant will report to the management staff of the OMAP.
• Assignments will be received verbally or in writing and will be carried out independently with minimal direct supervision. Work will be overseen through weekly status meetings with management. 
• Consultant, when requested, will work at one or more of the Department's work sites.
• Consultant’s primary work station will be at the Commonwealth Towers. Consultant will be provided with a desk, computer, phone, and all items necessary for him/her to complete assignments.
•  If Consultant is unable to appear at the scheduled work site at the pre-determined times, notification must be made to the Work Site Supervisor either prior to date or on date of absence.
• Consultant may be required to represent the Department at activities outside of Harrisburg. Reimbursement for travel required by the Department, will be made in accordance with the Commonwealth of Pennsylvania’s travel regulations.
• Work Product Deliverables
• Verbal or written assignments for on-going processes, standing work groups and projects will include specific and detailed descriptions of deliverables including nature of the work product, expected timeframes, available resources and desired outcomes. Progress towards interim goals and deliverables will be assessed during regular status meetings with the Bureau Director.
• Quality of work product;
• Appropriateness of work habits;
• Growth of knowledge base and skill set;
• Effectiveness of communications;
• Initiative and problem solving skills;
• Contributions to a productive and hospitable work environment;
• Effectiveness in oversight;
• Effectiveness in external liaison activities; and Consultant’s evaluation of OMAP work environment and quality of supervision/direction.

Additional work/duties for the Provider Service Center:

Possess a documented work history of two or more years of experience performing a provider relations, health care program monitoring, network management, demonstrate a basic understanding of medical terminology and administration or medical related call center experience.

Specific to the supervision of the provider service call center, the duties include (but not limited to): staff training and development; oversight and monitoring of non-pharmacy prior authorization and billing inquiries from MA enrolled providers for accuracy while adhering to MA program policies and procedures; ability to manage claims related inquiries with a high degree of difficulty from various internal and external parties; resolving high profile problems through research and communication; tracking system change orders and defects which affect the provider community and arrange for outreach to the providers when a resolution has been implemented; participate as a lead at staff meetings and as a member of multipole cross-functional teams as a subject matter expert; establishing goals and processes for a more efficient, productive & successful call center. The incumbent must also have knowledge and expereicene in the following areas: claim submission, processing & payments, provider billing, and knowledge of provider and recipient eligibility, provider enrollment and third-party liability systems and processes.

The incumbent supervisor will be responsible for performing the following personnel related duties to include employee recognition, coaching, disciplinary action, time and attendance, and performance reviews.

Oversees and ensures that inquiry staff have all of the necessary tools and access to various sources of online and printed materials to allow them to provide timely and accurate responses to inquiries in regards to Medical Assistance Program guidelines, regulations, policies and procedures. Disseminates new policy and procedures to ensure information provided is current and complete. Training will include (but not limited to) – CIS, OIM, PROMISe, Ma Program policies and Procedures, MA provider billing processes and procedures, MA prior authorization rules and regulations, Third Party Liability, and Enrollment.

Supervisory responsibilities also include determining work priorities, assigning work, reviewing work, scheduling leave, and handling grievances in compliance with both management level and rank and file contractual obligations to assure adequate staff is available to meet daily work requirements. Maintains current job descriptions of duti4es and prepares employee performance evaluation reports semiannually and/or annually.

Assists with resolution of complex provider issues. Complies high profile issues and/or MA questions related to Departmental procedures to include legislative inquiries, and appeal and denial hearings requiring resolutions to ensure resolutions. Assists with complex billing issue hearing filed with the Bureau of Hearing and Appeals.

Monitor staff to ensure efficient and effective use of Commonwealth resources and develops monitoring tools to allow for oversight of activities

About Us:

TulaRay partners with clients to create staffing solutions that meet unique organizational needs. Our services are designed to reduce administrative burdens, protect your brand, and improve assignment time-to-fill. We believe that mutually successful client relationships are built on lasting quality and exceptional customer service. We pride ourselves on our uncompromising commitment to high-quality emergency management & healthcare personnel, while ensuring that our clients are taken care of with personalized attention. TulaRay manages total compliance and respectfully supports hundreds of professionals and patient-centered programs.

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