Benefits Quality Control Manager 2025-02443

Description and Functions

• Draft and implement program State Plan Amendments (SPA), rules, and policies governing coverage and reimbursement of the following provider/service types: Dentists, Immunizations, Hospital providers, including Psychiatric, Critical Access, Ambulatory Surgical Care, Diagnosis-Related Groups for hospital payments (DRG), Hospital Outpatient Prospective Payment System (OPPS), and Rehabilitation Hospitals.
• Serve as the Wyoming Medicaid subject matter expert and contact person for benefit and reimbursement questions related to the following provider types/services: Dentists, Immunizations, Hospital providers including Psychiatric, Critical Access, Ambulatory Surgical Care, Diagnosis-Related grouper for hospital payments (DRG), Hospital Outpatient Prospective Payment System (OPPS), and Rehabilitation Hospitals.
• Participate in and lead medical and dental association meetings, national meetings/trainings, representing Wyoming Medicaid. Attend weekly/monthly/quarterly meetings with other Medicaid programs and Agencies within the federal government and providers.
• Plan, implement, monitor, and evaluate program performance, goals, and objectives for the Department's larger performance management program.
• Provide ongoing contract management for the Orthodontic review contract.

Qualifications

PREFERENCES:

The training and experience equivalent to a bachelor’s degree in public administration, business, accounting, healthcare administration, political science or other closely related field with three years of professional work experience in business, accounting, political science, healthcare or public administration.

• State government functions and procedures, including State and federal laws, policies, and procedures.
• Medicaid law and regulatory structure, including State and federal Medicaid statutes, regulations, and policies.
• Knowledge of accounting, budgeting, and data analysis.
• Concepts, principles, and practices of professional healthcare administration; challenges and trends in healthcare service provision.
• Contract procurement, negotiation, and administration.
• Accounting and budgeting in government.
• Legal requirements and procedures relating to rule promulgation.
• Administrative fair hearing process; citation and interpretation of complex legislation
• Program and time management, coaching and leading. Ability to balance multiple priorities and resources.
• Interpersonal relations, team building, and consensus building.
• Goal setting, performance evaluation and individual motivation.
• Research and analysis of complex problems as well as identification of options and solutions; decision making and evaluation of results.
• Public speaking, oral and written communication at a variety of levels and with multiple audiences
• Coordinate and motivate individuals and teams to undertake complex projects and achieve specific goals.
• Balance numerous demands on time using available resources.
• Ability to plan and analyze, conceptualize and communicate data analysis effectively.
• Quickly identify problems, prioritize needs, research solutions, and make decisions.
• Design and implement policies and processes in a timely, responsive, and cost-effective manner.
• Understand complex budgets, federal fiscal match, and how they apply to coverage and payment programs.
• Coordinate complex integration of unique program and system interfaces.
• Research and analyze issues related to Medicaid claims processing and payments, or to coverage and reimbursement policies under Wyoming Medicaid.
• Understand technology as it relates to Medicaid claims processing.
• Make decisions in the absence of the Provider and Benefits Management Unit Administrator.

Necessary Special Requirements

PHYSICAL WORKING CONDITIONS:

• The employee may sit comfortably to perform the work; however, there may be some walking, standing, bending, carrying light items, driving an automobile, etc.

• FLSA: Exempt
• The Wyoming Department of Health is an E-Verify employer.

Supplemental Information

URL: http://agency.governmentjobs.com/wyoming/default.cfm

The State of Wyoming is an Equal Opportunity Employer and actively supports the ADA and reasonably accommodates qualified applicants with disabilities.

Working for the State of Wyoming provides employees with a range of valuable benefits and offers a fulfilling career path. Employees enjoy comprehensive healthcare coverage, including medical, dental, and vision plans, ensuring their well-being and that of their families. Additionally, the state offers multiple retirement plans, which provide financial security and stability for employees once their career in public services comes to an end. the state recognizes the importance of personal time and offers generous paid time off and flexible arrangements, allowing employees to recharge, take care of personal matters, and maintain a healthy work-life integration.

There are many benefits to living and working in Wyoming. Beautiful country with wide-open spaces, clean air, great recreational activities, and no State income tax to mention a few!

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