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 Liability Leader - Remote
Summary of Job
Responsible for the oversight of cross functional activity related to Medicaid audits conducted by OMIG, AIG and their agents for Medicaid, Child Health Plus, HARP and other State Sponsored (“Medicaid”) lines of business. Responsible for ensuring that EmblemHealth and its delegates comply with encounter data submissions & reconciliation as well as retroactive enrollment audits for Medicaid, Child Health Plus, HARP and other State Sponsored (“Medicaid”) lines of business. Lead collaboration efforts with Enrollment, Compliance, Finance, Actuarial, Legal, Claims, and Pharmacy to ensure accurate and comprehensive delivery of audit requirements.
Responsibilities
• Lead cross‐functional activity related to Medicaid Audits conducted by DOH, OMIG, HMS and AG for audit types: Third Party Health Insurance; EmblemHealth and external Plans, Retroactive disenrollment (Incarcerated, deceased), Supplemental Maternity capitation, Family Planning, Nursing home placement, Foster Care, and Multiple Client Identification Number.
• Manage the tasks and projects exclusive of the OMIG audits themselves (handled by External Regulatory Audit (in Compliance function).
• Track findings identified by the auditors; ensure that all issues are addressed in full before the required deadline.
• Evaluate the impact of each finding, stratify findings in terms of impact on EmblemHealth, and provide appropriate recommendations to address each finding as needed, based on operational best practices and sound judgment.
• Provide analysis and recommendations to strengthen operations to limit current & future liability.
• Interface with external resources (Trade Associations (HPA/Manatt), outside counsel, OMIG, DOH).
• Partner with finance and business owners to ensure appropriate reserving for future audits during monthly financial close.
• Lead the collection, retention, and submission of encounter reimbursement offsets.
• Perform data analysis, cross referencing, etc., to facilitate accurate dispute analysis
• Partner with External Regulatory Audit function to manage incoming Medicaid regulatory communications, review & approve narrative responses to auditors.
• Lead cross collaboration with all operational departments impacted by audit activities to implement best practices.
• Produce and present reports to the Assistant Vice President on a regular basis on the status of all projects.
• Maintain a working knowledge of relevant issues, laws, regulations, and industry best‐practices to ensure operational.
areas across the Medicaid lines of business are compliant.
• Review/manage BHET/MMCOR liabilities by recommending and implementing mitigation strategies for prior time periods and for current/future time periods.
Qualifications
• Bachelor’s degree in healthcare, business administration, law, or related field; Master’s Preferred
• 10 – 12+ years’ experience in compliance‐related matters, preferably in the health care industry (Required)
• 3+ years’ experience with NYS Medicaid covering OMIG, MMCOR, or EIS/APD (SP)
• Staff and process management experience (Required)
• Understanding of the healthcare environment as it relates to liability potential (Required)
• Extensive experience with federal and/or state regulatory guidance (Required)
• Excellent communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences (Required)
• Proficiency with MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.) (Required)
Security Disclosure
If you are offered a job from one of the EmblemHealth family of companies that includes ConnectiCare, AdvantageCare Physicians, and WellSpark, the offer confirmation email will come from “HRTalentAcquisition” with the subject line: “Offer of Employment for (job title)” – Please respond online”.
We never ask you to join a Google Hangout, request you to purchase your own equipment or pay to apply. We do not send email from a third-party email service such as Yahoo or Gmail.
Pay Disclosure
A good faith estimate of the compensation range for individuals hired to work for the EmblemHealth Family of Companies is provided. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, internal peer equity, and market and business considerations. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. It is not typical for an individual to be hired at or near the top of the range, as compensation decisions depend on each case’s facts and circumstances. Union roles covered by a collective bargaining agreement will compensate in accordance with the union contract.
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/gender, sexual orientation, gender identity or expression, pregnancy or related condition, marital status, 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.