Program Coordinator II (Quality Review Specialist) ​/ 60020122

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

This is position is located in Bureau of Provider & Support Services,
Richland County. This is an in-office role and not a telecommute or remote position.

We are looking for a Program Coordinator II (Quality Review Specialist) who supports the successful delivery of quality control and audit functions for claims processing within the Bureau of Provider and Support Services. Works under general direction reporting to the Director of Support Services. Identifies and responds to claims related audits, external reviews, and internal quality control functions for claims processing for Fee For Service and Waiver beneficiaries specifically for Long Term Care (LTC), Hospice and Nursing Home Claims.

Has sound general, domain and specific knowledge of claims processing and demonstrates application of this knowledge. Applies methodical approach(es) to issue definition and resolution. Demonstrates effective communication skills. Demonstrates excellent customer service. Plans, schedules, and monitors own work within deadlines according to management.

• Develops Bureau-wide quality control plan and dashboard to include production and quality metrics for staff completing claims and provider services functions. Fosters a Bureau-wide commitment to quality assurance. Performs data collection, data analysis methodology, and implements performance improvement methods. Leads performance improvement projects and provide education and coaching in order to build needed skills in others. Coordinates with directors/managers to ensure continuous improvement efforts are integrated into all offices and sections, including staff responsibilities.
• Serves as the Bureau Lead for all audits (including internal, single state, PERM, etc.). Collaborate with stakeholders both within and outside of the Bureau to ensure all audit requests are completed timely and meet all requirements. Upon completion of audit, work with Bureau Directors to address any deficiencies and create corrective action plans to regain compliance.
• Serves as Bureau Lead for performing quality control audits of claims and provider services staff utilizing a combination of system reports and random sampling. Perform trend analysis for any repeat errors and collaborate with Bureau Director for remedial training of staff.
• Prepares reports and presents to management and external stakeholders related to processes, measures and outcomes, advising management of findings and recommendations. Leads organization toward a culture of continuous improvement.
• Manages special projects as directed by the Bureau Chief of Provider Services and Support related to the development and improvement of services within the Medicaid health care delivery system.
• Attends and participates in relevant opportunities for professional development and training. Demonstrates utilization and application of new skills learned to improve effectiveness and efficiency within assigned responsibilities.

• Health, Dental, Vision, Long Term Disability, and Life Insurance for Employee, Spouse, and Children.
• 15 days annual (vacation) leave per year.
• 15 days sick leave per year.
• 13 paid holidays.
• State Retirement Plan and Deferred Compensation Programs.

A bachelor's degree and one (1) year of relevant program experience.

An equivalent combination of education and experience may be accepted with prior State Human Resources approval.

• Valid driver's license.
• Occasional overnight travel.
• Sitting or standing for long periods of time.
• Lifting requirement: 20 lbs.
• In-office role.
• Ability to work independently; to organize and complete work assignments based on level of priority and importance and take appropriate action with minimal guidance.
• Ability to maintain a positive working environment with internal and external relationships.
• Capable of following oral and written policies/regulations.
• Must be able to maintain a strict level of confidentiality.
• Advanced skills with applications such as Microsoft Word and Excel.
• Knowledge of laws, regulations, policies and procedures relevant to the claims processing and related services for Hospice, LTC and Nursing Homes.
• Ability to exercise judgment and discretion.
• Ability to establish and maintain effective working relationships.
• Ability to interpret and apply laws, regulations, policies and procedures.
• Ability to communicate effectively.

The South Carolina Department of Health and Human Services is committed to providing equal employment opportunities to all applicants and does not discriminate on the basis of race, color, religion, sex (including pregnancy, childbirth or related medical conditions, including, but not limited, to lactation), national origin, age (40 or older), disability or genetic information.