Provider Network Auditing Supervisor

SCCMHA JOB VACANCY ANNOUNCEMENT

CLASSIFICATION: Provider Network Auditing Supervisor

Pay Range: $80,060.84 - $105,916.41 annually

POSITION SUMMARY:

Under general supervision of the Manager of Network Services and Supports, responsible for supervising the provider network services auditing program of the Saginaw County Community Mental Health Authority (SCCMHA). The auditing unit is responsible for part of a compliance and quality performance program to safeguard against fraudulent or erroneous claims of persons served service provision and is a primary source of the required monitoring of provider performance on behalf of SCCMHA. Oversight of audit functions includes both contracted and SCCMHA operated services and program units that provide direct services to persons served. The position develops and refines audit tools and processes that meet SCCMHA contractual and legal obligations by source reference. The position ensures proper and professional documentation and appropriate routine communications of provider monitoring and event verification functions as well as integrity and consistency in the audit process, measures, and data. Provides analysis and summary data to the SCCMHA management team on audit outcomes as planned or requested. Coordinates unit functions with contract management, training, and recipient-rights areas, as well as other programs or units of SCCMHA as indicated. This position also oversees the aspects of Home and Community Based Services Rules This position will be knowledgeable about and actively support culturally competent recovery based practices; person centered planning as a shared decision making process with the individual, who defines his/her life goals and is assisted in developing a unique path toward those goals; and a trauma informed culture of safety to aid persons served in the recovery process.

ESSENTIAL DUTIES AND RESPONSIBLITIES:

1. Supervises the provider network audit function. Key aspects of the auditing function include at minimum an annual provider monitoring process against established standards and the review of a minimum number of random service events against claims and other records to ensure proper documentation of publicly funded services. Ensures that provider network services audit requirements measure provider performance against the comprehensive standards and requirements of SCCMHA.

2. Supervises the implementation of an annual audit plan to meet organizational goals. Responds to ad hoc audit needs, including provider performance concerns of validity of purchased or SCCMHA provided services. Oversees the establishment of audit samples, schedules and plans for audit team members. Conducts presentations on the audit function or outcomes to provider groups and SCCMHA departments. Ensures the SCCMHA audit schedule and related time frames are maintained. Supervises provider network data base and audit files relative to audit scores and supporting detail. Ensures meaningful persons served involvement by policy or as appropriate in the provider monitoring function. Supervises SCCMHA required submission of corrective action plans by providers and monitoring to meet standard or improvement goals.

3. Hires, orients, trains and supervises department staff. Creates audit schedule and assigns specific audits or audit tasks to provider network auditors. Reviews all audit reports and provider corrective action plans. Coordinates function and auditors work with other SCCMHA departments or units. Provides specific and appropriate priority coordination with Contract and Training department staff on provider performance, as well as SCCMHA Fiscal and Compliance staff on provider event verification matters.

4. Supervises audit program development; recommends modifications to tools, procedures, or documentation to improve processes or to meet changing policies or requirements of SCCMHA. Ensure provider feedback on audit process and plans. Responds to provider type communication needs or issues regarding audits and event verification. Recommends quality improvements in the audit area to SCCMHA management. Stays abreast of provider documentation and organizational compliance requirement changes.

5. Issues routine audit program reports or summaries or ad hoc reports as requested or indicated. Participates in and contributes to quality improvement, compliance, contract, or fiscal management, clinical management, or recipient rights coordination of department.

6. Works with department and management leadership, including SCCMHA contract management, finance, operations, clinical services and compliance and quality areas to improve audit program and functional operations.

7. Alerts Department and SCCMHA management regarding serious, immediate findings.

8. Alerts the Office of Recipient Rights of any issues that might pertain to a violation of the Michigan Mental Health Code.

9. Provides education to staff or providers either one-on-one or in a group setting to clarify audit standards.

10. Works with Mid-State Health Network (MSHN) on performance reviews as part of the reciprocity agreements.

11. Provides leadership and coordination for all MSHN, MDHHS and other site reviews that include the need for gathering of proof documents from the provider network.

12. Provides leadership and coordination with SCCMHA Human Resources for any documents required for MSHN, or MDHHS reviews.

13. Provides leadership and is involved in the MSHN Medicaid Event Verification process.

14. Attends all MSHN workgroups related to audit functions for the Fiscal Management Services (FMS), Licensed Inpatient Hospital Units (LPH), Applied Behavioral Analysis (ABA), and Healthy Transitions Crisis Residential Unit (CRU) reviews.

15. Interprets and implements changes in federal, state, PIHP, and organizational requirements affecting provider monitoring, auditing, and compliance activities.

Supervises Residential Placement Liaison and Home and Community Based Services (HCBS) Coordinator

1. Oversees the workload and function of the Residential Placement Liaison and HCBS Coordinator.

2. Assures the HCBS Coordinator is educated and familiar with the Home and Community Based Services (HCBS) Rules and is able to vet any new residential contracts for compliance with these rules. Monitors ongoing compliance with HCBS rules.

3. Assures the routine agendas and minutes are completed by the Residential Placement Liaison for the Residential Placement and Residential Watch Committees.

4. Assures the Residential Placement Liaison is vetting and reviewing any potential specialized residential settings as well as General AFC settings to meet the needs of persons served.

5. Attends the MSHN HCBS workgroup and provides feedback to appropriate stakeholders.

6. Ensures that all information relevant to contract action is communicated and approved by designated management team members.

7. Performs other duties and responsibilities as assigned by supervisor.

8. Communicates the mission, vision, and core values of SCCMHA to staff while holding them accountable and implements these principles in all duties of this position.

INCIDENTAL DUTIES AND RESPONSIBILITES:

1. Represents the unit or department/department director as requested at internal or provider meetings.

2. May attend conferences, workshops, seminars and read job-related publications to maintain professional competency in position.

(The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all duties and responsibilities required of personnel so classified.)

REPORTING RELATIONSHIPS:

Reports to: Manager of Network Services and Supports

Supervises: Peer Auditing Representative, Provider Network Auditor(s), Residential Coordinator and Network Auditor, and Typist Clerk(s)

WORKING CONDITIONS/ENVIRONMENT:

Works in normal office environment with usual pressures of dealing with time constraints. Works as a supervisor of an audit team/unit and department member. Because of multiple provider sites of SCCMHA and the need to visit some programs on site, it is common to drive to several locations, sometimes in bad weather

QUALIFICATIONS:

Education: Bachelor’s degree in social work, psychology, or closely related Human Services field and knowledge of health care administration, or a Bachelor’s in a business-related area, with specific program or financial auditing experience. A Master’s degree is preferred.

Experience: A minimum of five (5) years of experience in health care, business or related financial or program field is required; although clinical experience is helpful, experience must include some business-related functions. Audit and/or data analysis experience preferred. Human service experience and/or knowledge preferred. Business, finance, and computer skills, including spread sheet functions, are required. A general knowledge of mental health systems, and compliance or medical records desired. Must be able to provide samples of varied, quality written work.

Licenses and Certifications: Valid Michigan Driver’s license with a good driving record.

Knowledge, Skills, and Abilities:

1. Analytical ability, finance, math and/or research skills, organization strengths and effective written and verbal communication skills are essential.

2. Ability to prepare professional routine correspondence or analytical reports is essential.

3. Computer skills are required.

4. Ability to exercise independent and mature judgment; diplomacy, discretion, interpersonal problem-solving, and attention-to-detail abilities are required.

5. Ability to manage conflict and quickly shift and/or manage multiple work priorities.

6. Ability to represent the organization in a positive, professional manner.

7. Ability to provide educational support to providers on service topic and provider compliance areas.

Physical/Mental Requirements:

1. Hearing acuity to converse in person and on telephone.

2. Visual Acuity to read and proofread documents and use electronic health record.

3. Ability to walk, stand or sit for extended periods of time.

4. Manual dexterity to write and to operate standard office equipment (PC, Keyboard, Copy Machine, Fax Machine, etc.)

5. Ability to lift and carry files and supplies at least 20 pounds.

6. Strong interpersonal skills to interact with leadership, employees, persons served and the general public.

7. Analytical skills necessary to conduct research, analyze, and interpret complex data and identify and solve problems by proposing courses of action.

8. Ability to plan short and long range and to manage and schedule time.

9. Ability to handle stress in meeting deadlines and dealing with large numbers of employees and/or persons served.

(Listed qualifications are for guidance in filling this position. Any combination of education and experience that provides the necessary knowledge, skills, and abilities will be considered; however, mandatory licensing or certification requirements cannot be waived. Physical/mental requirements cannot be waived unless specifically indicated.)