+--------------------+--------------------+--------------------+--------------------+ | DEPARTMENT: | Quality Assurance | FLSA STATUS: | Exempt | | | & Compliance | | | +--------------------+--------------------+--------------------+--------------------+ | REPORTS TO: | Sr. Quality | PHYSICAL STRENGTH: | Light (L) | | | Assurance & | | | | | Compliance Manager | | | +--------------------+--------------------+--------------------+--------------------+

+--------------------------------------------------------------------------+ | SUMMARY | | | | This position is responsible for processing, evaluating, and tracking | | incoming referrals relating to allegations of fraud, waste, and abuse | | (FWA) in the Medicaid line of business. Conducts research and performs | | data retrieval and analysis as a member of the Quality Assurance & | | Compliance Department by performing the following duties. | | | | ESSENTIAL DUTIES | | | | - Serves as the initial contact during the case intake process | | following the receipt of information and allegations about suspected | | FWA from internal and external sources. | | - Consults with the Sr. Quality Assurance and Compliance Manager on | | all referrals made to the Oregon Department of Justice Medicaid | | Fraud Control Unit (MFCU) and the Oregon Health Authority Program | | Integrity Audit Unit (PIAU). | | - Oversees subcontractor activities to ensure compliance with the YCCO | | Compliance and Fraud, Waste, and Abuse Programs. | +--------------------------------------------------------------------------+

JOB DUTIES

• Assists Sr. Quality Assurance and Compliance Manager with Fraud, Waste and Abuse Program, including maintenance of annual YCCO FWA Plan and Handbook.
• At case intake, processes, prioritizes, analyzes, documents, and tracks referrals and conducts background research, gathers supporting documentation, retrieves and reviews records, and coordinates with other departments.
• Proactively performs records and data retrieval from TPA and providers, data mining, analysis, and research to identify potential opportunities to investigate suspected FWA to support of a full range of investigative functions from case development to referral in a timely manner.
• Communicates updates on assignments to supervisors, managers, and other departments and committees.
• Assists with the preparation and delivery written documents and oral briefings and presentations on potential FWA cases and other related activities.
• Assists with the development and implementation of initiatives and the completion of regulatory planning and reporting requirements.
• Engages in outreach with internal and external partners, regulators, and vendors, to ensure the completion of assignments.
• Supports legal proceedings as necessary, including law enforcement subpoenas, data requests, and preparation for civil or criminal actions.
• Responsible for delegation oversight, including subcontractor monitoring, and reports findings and successes to Sr. Quality Assurance and Compliance Manager.
• Assists with delegation oversight duties, including subcontractor monitoring.
• Coordinates and/or assists with all delegated activities to ensure compliance with state, federal, and YCCO requirements, such as performing analysis of annual due diligence audits and monitoring delegated activities.
• Monitors post-audit delegated activities to ensure compliance with OHA and CMS requirements. Examples include tracking receipt of and monitoring quarterly/yearly reports from delegated entities and assisting with development and implementation of Corrective Action Plans as non-compliant issues are identified.
• Monitors Service Level Assessments from subcontractors. Examples include tracking, analyzing and trending measures, determining and reporting 'outliers' to Sr. Quality Assurance and Compliance Manager, and other management reporting.
• Reviews all pre-delegation audits from entities applying for a contract with YCCO, as well as post-delegation audits at contract end.
• Assists the Sr. Quality Assurance & Compliance Manager with deliverable timelines and submission.
• Develops and implements tracking tools to ensure timely issue resolution and compliance with all applicable standards.
• Works with the YCCO Compliance and Audit Specialist to coordinate annual risk assessment audits.
• Develops FWA-related policies and procedures.
• Responsible for quarterly and annual FWA reporting due to CCO’s contractor.
• Performs matrixed work with other YCCO departments as needed, including Healthcare Services and Finance.
• Respectfully takes direction from manager.

ESSENTIAL DEPARTMENT AND ORGANIZATIONAL FUNCTIONS

• Proposes and implements process improvements.
• Meets deadlines for completion of workload.
• Maintains agreed upon work schedule.
• Demonstrates cooperation and teamwork.
• Provides cross-training on specific job responsibilities.
• Meets identified business goals that contribute to departmental goals.
• Performs other duties as assigned.

KNOWLEDGE, SKILLS, AND ABILITIES

• Excellent computer skills are needed, with a strong proficiency in Excel and similar tools and the ability to effectively manipulate and organize complex data.
• Curious, detail-oriented, and inquisitive mindset.
• Organizational and time management skills, along with an ability to skillfully handle time-sensitive projects. Analytical, problem-solving, and decision-making skills to work through challenging and complex case details.
• High degree of integrity and confidentiality required for handing information that is personal and confidential. Strong written and verbal communication skills, including the ability to obtain information from others and deliver information in a concise, clear, and accurate manner.
• The ability to navigate and understand claims data and various databases to identify and document suspected FWA.
• Ability to work collaboratively, build coalitions and resolve conflicts, including success in managing cross functional initiatives.
• Interpersonal skills, with the ability to listen, coach, and provide technical direction to others and to interact with tact and professionalism with all levels of the organization and external contacts.

SUPERVISORY RESPONSIBILITIES

This position has no supervisory responsibilities.

QUALIFICATIONS

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

EDUCATION & EXPERIENCE

Bachelor’s degree in relevant healthcare, investigations, or related discipline or equivalent experience with minimum two years’ related work experience, required. Master’s degree, preferred. Minimum two years’ fraud, waste and abuse experience, required. Minimum four years’ experience in quality management and regulatory experience, required. Credentialing and/or medical coding experience, preferred. Knowledge of Oregon’s Medicaid program, preferred. Experience completing delegation oversight assessments/audits, preferred.

CERTIFICATES, LICENSES AND/OR REGISTRATIONS

Valid driver’s license, acceptable driving record, and automobile liability coverage or access to an insured vehicle, required.

PHYSICAL DEMANDS & WORK ENVIRONMENT

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this position. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to sit, stand, walk, use hands and fingers, handle or feel, and reach with hands and arms. The employee is occasionally required to climb or balance, stoop, kneel, crouch or crawl. The employee may occasionally need to lift and/or move up to 25 pounds.

This position operates in a professional office environment and requires frequent use of standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Specific vision abilities required by this job include close vision, color vision, distance vision, depth perception, and ability to adjust focus. The noise level in the work environment is usually moderate.

This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.