Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

Medicaid Delegate Oversight and Compliance Lead

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Manager & Professional
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191GC Requisition #
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Accountable for oversight of the HPC and Monte delegation agreements or the Beacon delegation agreement from a Medicaid perspective.  Ensure communication and compliance the Medicaid, HARP and CHP contract and regulations.  Communicate existing requirements, new requirements, and carve in of benefits and populations.  Manage corrective actions and improvement plans.  Embed at the delegate work location when possible.

Responsibilities:
  • Understand, communicates, and explains contract and regulatory requirements to delegates.
  • Ensure delegates implement contract requirements and applicable regulations.
  • Develop audit plan and conduct audits of delegates to ensure compliance with the contract and applicable regulations. 
  • Perform root cause and impact analysis.
  • Develop corrective actions plans in collaboration with the delegates and oversees implementation.
  • Attend the Delegation Oversight Committee and report on audit findings.
  • Apply project management methodologies to lead implementation initiatives working in collaboration with internal business owners and delegate staff.
  • Provide recommendations to Senior Leadership for continuous improvement to promote effective and efficient operations.
  • Work with the Director for Behavioral Health and the appropriate medical directors/clinical staff at EmblemHealth to ensure audits of clinical records are conducted.
  • Identify root causes where deficiencies are found with clinical staff at EmblemHealth to develop corrective action plans.
  • Collaborate with the EmblemHealth clinical team to ensure corrective action plans are implemented and are effective, and to ensure that members are managed effectively.
  • Work with internal business owners to ensure that delegate claims are paid accurately and timely.
  • Develop scorecards for all operational and clinical functions and implement those with delegates. 
  • Review dashboards and metrics and identify areas of concern.
  • Develop and oversee the implementation of action plans to address areas of concern.
Qualifications:
  • Bachelor’s degree required 
  • 4 -6 years’ work experience in regulatory healthcare operations compliance required
  • Thorough knowledge of State and/or Federal programs operations and regulations required
  • Proficiency in the use of Microsoft Office (Word, Excel and Access) required
  • Strong analytical skills required
  • Proven ability to establish and maintain relationships of trust with departmental staff and management required
  • Proven ability to coordinate and lead interdepartmental work teams and meet established goals required
  • Must be goal oriented and able to meet tight deadlines while handling multiple priorities required
  • Must be a team player and able to take direction from multiple sources required
  • Must be highly organized, able to handle multiple assignments with overlapping deadlines. Must have the ability to show attention to detail required
  • Excellent communication skills (written and verbal) required. Ability to communicate clearly and concisely with EmblemHealth staff and management required
  • Ability to arrange work schedule to meet deadlines from multiple sources, and engage staff throughout EmblemHealth to assist in the completion of duties required

EEOC Statement

We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.

Sponsorship Statement

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.

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