Compliance Analyst

Recruitment #210218-UNCB-44

Introduction

 

 

  

POSITION PURPOSE:
The incumbent will be under the general direction of the QA/SoonerCare Compliance Manager.  The incumbent will assist in the review and reporting of referrals and claims data to analyze provider compliance with contractual standards, as well as the coordination, resolution and compliance of SoonerCare member and provider issues received through the Oklahoma Health Care Authority according to OHCA established rules.  The incumbent will assist in the general planning and development of special projects related to the operational, implementation, and development activities for SoonerCare.

PRINCIPLE ACTIVITIES: 
*Analyzes referrals and claims data to determine utilization patterns. Gathers pertinent information using the MMIS system. Writes reports containing detailed findings and recommendations based on these analyses.
*Assists with the researching, investigation and resolution of complaints or issues related to the SoonerCare program received from or identified by providers, clients, and other state agencies and community groups. Analyzes data from the MMIS system and reviews Medicaid policy in order to resolve issues.  Coordinates issue tracking process.
*Assists with the coordination of analyses of SoonerCare reports to identify, reconcile and report on issues and trends.
*Proficient use of: databases such as ACCESS; Adobe Pro; Microsoft office applications such as Outlook, Word, Excel, PowerPoint, OneNote, and SharePoint .
*Analyses of encounter data including validation of submitted encounter claims and identification of providers who may not be submitting encounters.
*Collaborates with Quality Assurance/ team in the identification of quality assurance activities, as related to strategic work plan development, and utilization analyses.
*Collaborates and coordinates with Office of Data Governance and Analytics to maintain and continually approve team dashboard.
*Attends meeting inside and outside the agency as SoonerCare representative.
*Disseminates public information to individuals, business groups, community representatives and other program stakeholders. 
*Coordinates Quality Assurance complaint process from creation to closing, including QIO referrals, tracking and related certified mail steps.
*Ownership of medical records requests related to investigation of member/provider complaints and other Quality Assurance referrals.
*Maintains updated Medical Education and Intervention Team tracking database.
*Regarding quarterly retrospective review reports:  reconciliation, basic trending, isolating Quality Determinations and opening QA issue (investigation tracking file) for those determinations.
*Regarding Quality Assurance Advisory Group:  create, compile and distribute pre-meeting documentation (agenda, files, etc), meeting notes, meeting-related database tracking, logging of legal notices, terminations, and other related actions; produce adhoc reports, often provider-specific.
*Coordinate routine staff meetings for QA Manager’s team, order department supplies, department meeting minutes.
*Assists investigations by performing licensure board queries.
*Maintains process mapping for the QA Manager’s team.
*Other duties as assigned.

EDUCATION AND/OR EXPERIENCE:
Bachelor’s degree; OR 4 years of related experience in quality assurance, data analysis, or complaint resolution and experience in using a database computer program; OR an equivalent combination of education and experience, (substituting 30 semester hours for each year of experience) totaling 4 years. 

PREFERENCE MAY BE GIVEN TO CANDIDATES WITH:
*MMIS or MIS operations experience or education
*SoonerCare experience
*Quality assurance experience
*Advanced education.

The Oklahoma Health Care Authority complies with applicable Federal civil rights laws and does not discriminate.  All qualified applicants will receive consideration for employment without regard to race, color, sex, religion, disability, age, national origin, or genetic information. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact the Civil Rights Coordinator at 405-522-7335.

 

 

Conclusion

Veteran’s preference points apply only for initial appointment in the classified service.