Program Manager II; Director of Targeted Oversight

The Agency's mission is to be boldly innovative in improving the health and quality of life for South Carolinians.

This position is located in Bureau of Managed Care, Richland County. This is an in-office role and not a telecommute or remote position.

We are looking for a Program Manager II (Director of Targeted Oversight) who reports directly to the Assistant Bureau Chief of Managed Care and oversees a team focused on targeted Managed Care Organization (MCO) oversight. The role focuses on compliance monitoring in areas such as encounter submissions, provider network adequacy, member grievance and appeals, service authorizations, provider disputes, and MCO subcontracting arrangements.

It aligns managed care policy and reporting requirements, ensuring MCOs follow federal and state regulations and SCDHHS strategic plan and contract requirements. This position also serves as the business owner for external vendor contracts to support regulatory and MCO oversight. The Director collaborates frequently with internal and external stakeholders (Medicaid and Dual Managed Care Plans, SCDHHS, CMS, etc.) to ensure effective service provision and operations under Medicaid and related programs.

• Under the supervision of the Assistant Bureau Chief, uses Federal regulations, State Regulations, SCDHHS Strategic Plan, the Managed Care Contract, and Managed Care Report Companion Guide to develop specific deliverables to be monitored by the Office of Targeted Oversight staff. Works with the Managed Care Contract Writer and other internal stakeholders to ensure the Managed Care Contract and associated Report Companion Guide accurately reflect reporting requirements and are updated to meet requirements and further the strategic goals of the agency.
• Oversees and works with Provider Network Analyst and SCDHHS vendors/contractors on routine Managed Care Provider Network analysis. Ensures that the MCOs are accurately reporting contracted network providers to SCDHHS. Deficient network adequacy results will be handled as described in the MCO contract which includes a progressive set of increasing sanctions.
• Compares and validates required data reports are submitted as defined by the MCO Contract and Report Companion Guide. Reviews reports for discrepancies and accuracy. Analyzes the results of submitted MCO reports, comparing the data from each MCO looking for patterns and outliers between each MCO. Creates a health plan score card with the results of the MCO reporting for internal stakeholders.
  
  Follows up with the MCO when discrepancies or outliers are found in the data. The actions may include progressive sanctions as necessary to modify MCO behavior. Reviews and validates internal reporting by Managed Care data analyst.
• Oversees quarterly and annual reports submitted by the MCO’s regarding Grievance and Appeals, Service Authorizations, and Provider Disputes. Ensures that MCO’s are providing accurate and timely reports and meet contractual and/or regulatory guidelines. Deficiencies in these areas of oversight will be addressed as described in the MCO contract, which includes a progressive set of increasing sanctions.
• Oversees monitoring and analysis of MCO Encounter Data through quarterly and annual reports submitted by MCO’s and engagement with EPS. Ensures that MCO’s are providing accurate and timely reports, meet contractual and/or regulatory guidelines, and identified key performance indicators as related to encounters submitted by MCO’s. Deficiencies in these areas of oversight will be addressed as described in the MCO contract, which includes a progressive set of increasing sanctions.
• Performs fundamental supervisory and leadership functions in accordance with Department policies and procedures, best practices and Federal and State rules and regulations, especially with regard to Equal Employment Opportunity Commission (EEOC) standards. Maintains an effective organizational team and motivates staff to accomplish mission critical operations and objectives. Promotes workforce engagement.
• Leads or supports other projects proactively or as assigned by Agency leadership. Projects may require driving to…