Assistant Director, Nursing & Waiver Services; Program Manager Iv

STD
0022

MDH, Office of Long-Term Services and Supports, Baltimore, MD

This position serves as the Assistant Director for Waiver and Nursing Services directorate within the Office of Long-Term Services and Supports ( OLTSS ). The Assistant Director plans and directs the functional operations and processes for the following divisions:
Division of Provider Integrity, Claims, and Compliance;
Division of Clinical Support;
Division of Participant Enrollment and Service Review; and the Division of Nursing Services. Additionally, the incumbent is responsible for the Financial Management and Counseling Services (FMCS) contract implementation, oversight, and monitoring. The Assistant Director manages the case management hierarchy and oversees the coordination of services for dually-enrolled Medicaid participants.

The Division of Provider Integrity, Claims, and Compliance, Division of Clinical Support, and the Division of Participant Enrollment and Service review are responsible for the operations of the Community First Choice (CFC), Community Personal Assistance Services (CPAS), Increased Community Services (ICS), and Home and Community-Based Options Waiver ( Community Options ) programs. In addition to operating these programs, this triad is responsible for maintaining the federal authorities associated with each program, engaging with stakeholders, drafting and implementing regulatory and subregulatory guidance, and performing quantitative and qualitative analyses to inform decisions related to program operations.

Each division is responsible for certain functions as noted below.

The Division of Provider Integrity, Claims, and Compliance is responsible for monitoring provider compliance with the home and community-based services (HCBS) settings rule – specifically, ensuring that individuals with disabilities receiving HCBS have the same opportunities as individuals without disabilities and are fully integrated in their communities. As such, division staff conduct onsite visits and desk reviews to ascertain provider compliance, provide technical assistance, and initiate disenrollment for non-compliance providers.

Additionally, division staff process manual claim adjustments, assist providers with billing concerns, and provide technical assistance to providers interested in becoming a Medicaid-enrolled provider.

The Division of Clinical Support is comprised of clinical and non-clinical staff. The clinical staff conduct utilization review on medically complex plans of service for applicants and participants in the CFC, CPAS, ICs, and Community Options programs. Additionally, the clinicians serve as expert witnesses in appeal hearings to defend the Department’s decisions. Both non-clinical and clinical staff investigate reportable events and make referrals to other agencies as appropriate.

This division provides oversight of the nurse monitoring program, completion of the interRAI assessment, and completion of the Pre-admission Screening and Resident Review (PASRR) Level II performed by the Local Health Departments (LHD) across the State.

The Division of Participant Enrollment and Service Review has three units – Plan of Service, Registry, and Enrollment. This team conducts utilization review for plans of service for applicants and participants in the CFC, CPAS, ICs, and Community Options programs. The registry team manages the Community Options registry and completes the monthly wave to invite individuals from the registry to apply for the program.

The enrollment team reviews technical eligibility for the four aforementioned programs and processes the authorizations to participate in the programs. This division is responsible for management and oversight…