Audits Manager ; Reimbursements Manager - NHs AND FQHCs

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 Reimbursements, Richland County. This is an in-office role and not a telecommute or remote position.

Are you the One? We are looking for an Audits Manager I (Reimbursements Manager - Nursing Home & Federally Qualifying Health Centers) who will manage the team implementing Medicaid reimbursement policies and rate‑setting methodologies for Nursing Homes (NHs) and Federally Qualifying Health Centers (FQHCs). The role ensures provider payments are accurate, compliant with State and Federal regulations, and aligned with program goals.

It also ensures the accuracy and completeness of staff analyses and deliverables through regular review and guidance.

• Manage the efforts to request, collect, track, and store digital copies of Medicaid Cost Reports for NHs. Interpret and apply legislative regulations found in the State Plan to calculate specific and statewide Nursing Home Rates along with Swing Bed and Administrative Day Rates. Prepare NH Rates for submission to CMS and ensure approved rates are submitted for input to SCDHHS’ claims‑handling application, Medicaid Management Information System (MMIS).
  
  Review the team’s calculation of Nursing Home Settlements for retro‑rate adjustments based on Audits or Consent Orders. Review NHs annual submissions of Professional Liability Claims support for compliance and calculations of amounts to reimburse NHs per the State Plan. Ensure accurate communication of Requests, Payments, Rate Changes, and Reimbursement Methodology changes to NHs. Maintain audit‑ready documentation for all data sources, calculations, methodologies, approvals, and rate‑setting decisions.
• Use Excel Macros and software applications to extract relevant data from both Medicare and Medicaid Cost Reports. Run and review Statistical Analysis System (SAS) queries that extract claims data from MMIS’ reporting layer and ensure a proper understanding of the output. Prepare Upper Payment Limit Demonstration for Nursing Homes for CMS. Periodically review and reconcile Reimbursement Payment Logs for audit purposes.
  
  Respond to FOIA (Freedom of Information Act) requests for NHs. Ensure accurate communication of Requests and Reimbursement Methodology changes to NHs. Maintain audit‑ready documentation for all data sources, calculations, methodologies, and approvals.
• Describe:
  Manage the efforts to request, collect, track, and store digital copies of both Medicare and Medicaid Cost Reports for FQHCs. Use Excel Macros and software applications to extract relevant data from both Medicare and Medicaid Cost Reports. Interpret and apply legislative regulations found in the State Plan to determine rates for new FQHCs and ensure these rates are submitted properly for input to SCDHHS’ claims‑handling system, MMIS.
  
  Review FQHCs Change in Scope submissions to confirm compliance with state and federal regulations. Calculate rate adjustments for FQHCs based on properly submitted Change in Scope requests. Quarterly review of staff’s determinations, calculations, and data pulled to support supplemental wrap payments that ensure FQHCs receive legislated payments for certain Fee‑for‑Service Dental services or certain services paid by Managed Care Organizations.
  
  Periodically review and reconcile Reimbursement Payment Logs for audit purposes. Run and review SAS queries that extract claims data from MMIS’ reporting layer and ensure a proper understanding of the output. Respond to FOIA requests for FQHCs. Ensure accurate communication of Requests, Payments, Rate Changes, and Reimbursement Methodology changes to FQHCs. Maintain audit‑ready documentation for all data sources, calculations, methodologies, approvals, and rate‑setting decisions.
• Review staff’s monthly preparation of NH Expenditure and Utilization Reports prior to submission to the Director and Chief of the Bureau. Complete research to include running SAS queries to verify and confirm completeness and accuracy based on the identification of anomalies by Management or internal and external inquiries received by…