<p>Job Responsibilities</p> <p>The Agency's mission is to be boldly innovative in improving the health and quality of life for South Carolinians.</p> <p>This is position is located in Program Integrity/SURS, Richland County.</p> <p>This is an in-office role and not a telecommute or remote position.</p> <p>Are you the One? We are looking for a Program Coordinator II (Ancillary Review Coordinator) who detects, investigates, and identifies instances of suspected providers and recipient fraud or abuse of the Medicaid Program.</p> <ul> <li>Analyzes provider records to ensure compliance with program guidelines, policies and procedures; coordinates case actions with program staff during the review process regarding potential overpayments and appropriate administrative sanctions; identifies and recommends policy changes that will improve program operations. Develop case reviews as determined to 1) Conduct unannounced onsite visits and obtain medical records (2) Request medical records, 3) Send provider/recipient survey letters, 4) Send provider self-audit letters, 5) Request additional information or documentation, 6) Make telephone calls to recipients to verify services, 7) Coordinate and correspond case actions with Manage Care Organizations (referring providers timely should it be warranted), 8) Coordinate and correspond cases and complaints with the investigator. Review all information received and conduct a comparison review between the Medicaid paid claims, applicable Medicaid rules and regulation and policy on all documentation or information obtained. Verify appropriateness and medical necessity of services billed to Medicaid. Determine if a fraud referral is warranted and coordinate with manager to complete a referral to the SC Medicaid Fraud Control Unit (SCMFCU) of the SC Attorney General's Office. </li><li>Learn and utilize the current Business Information Systems (BIS), SAS, MMIS, etc. Be able to develop special reports in accordance with trends within the provider community. Set up and run detail claims report (DCRs) and focused reports as needed in SAS. Be able to utilize SAS to identify aberrant billing of providers by researching the Fraud Frame Work. Conduct evaluation and analysis of provider statistical profiles and details claims report generated by SURS/SAS reporting system which is the first line review of data to include analysis and evaluation of exception criterial and profile reports as well as generate reports of paid claims data. Be able to research and triage alerts in SAS Fraud Framework. </li><li>Perform post payment review of providers while maintaining sufficient number of cases as directed by management. Evaluates paid claims history data and determine patterns of practice and adherence to Medicaid program policy and procedures. Researches information and makes decisions using requisite knowledge and expertise evaluating health delivery patterns of individual providers and specialties. Use appropriate methodology to conduct comparison studies, focus reviews, and random sampling, review universe of claims, self-audit, line by line sample or random sampling. </li><li>Coordinate and schedule informal conferences with providers as necessary. Coordinate pre-hearing meetings with the pertinent agency staff. Documents the informal conference and or appeal process. Coordinate case with the office of General Counseling as needed. Defend cases in Fair Hearing as scheduled. </li></ul> <p>The South Carolina Department of Health and Human Services offers an exceptional benefits package for FTE and TGE positions that includes:</p> <ul> <li>Health, Dental, Vision, Long Term Disability, and Life Insurance for Employee, Spouse, and Children. </li><li>15 days annual (vacation) leave per year. </li><li>15 days sick leave per year. </li><li>13 paid holidays. </li><li>State Retirement Plan and Deferred Compensation Programs. </li></ul> <p>Minimum and Additional Requirements</p> <p>A bachelor's degree and relevant program experience.</p> <p>Preferred: A bachelor's degree and at least one (1) year of experience in health services or a related program area.</p> <p>Additional Requirements:</p> <ul> <li>Valid and maintained driver's license. </li><li>Ability to drive state vehicles. </li><li>Travel statewide. </li><li>Sitting or standing for long periods of time. </li><li>Occasional overnight travel. </li><li>Overtime and/or weekend work with Deputy approval. </li><li>Lifting requirements: 30 lbs. </li><li>In-office role. </li></ul> <p>Preferred Qualifications</p> <ul> <li>Thorough knowledge of health care trends and practices. </li><li>Utilize PC, printers, calculator, Xerox machines, fax machine, scanners, and laptop computers. </li><li>Ability to communicate effectively. </li></ul> <p>Additional Comments</p> <p>Please complete the State application to include all current and previous work history and education. A resume will not be accepted nor reviewed to determine if an applicant has met the qualifications for the position. Supplemental questions are considered part of your official application for qualification purposes. All applicants must apply online. All correspondence from the Office of Human Resources will be through electronic mail.</p> <p>The South Carolina Department of Health and Human Services is committed to providing equal employment opportunities to all applicants and does not discriminate on the basis of race, color, religion, sex (including pregnancy, childbirth or related medical conditions, including, but not limited, to lactation), national origin, age (40 or older), disability or genetic information.</p>