IBM Watson Health - Project and Case Disposition Manager in DES MOINES, Iowa

Job Description

The Project Manager is responsible for oversight of key components of the Iowa Medicaid Enterprise (IME) Program Integrity project, providing overall project management for IBM’s Program Integrity team supporting the IME PI Unit, and managing the Audit and Investigative process and directing the case disposition team to achieve program objectives. This position will organize and oversee the workload of these functions and will coordinate activities with audit subcontractor(s) and/or managed care organizations’ (MCO) special investigation units (SIUs) and other stakeholders where appropriate. The Project Manager is responsible for the timely documentation, follow up, resolution and outcome of each fraud, waste and abuse (FWA) case and related case matters.

Primary Responsibilities:

  • Develops policies, procedures, processes and workflows to support the audit, investigative and case disposition process.

  • Sets priorities for project management and case disposition workload and recommends goals and objectives for the Audit, MCO Oversight and case disposition teams.

  • Provides input into the configuration, testing, implementation and ongoing operations of the case management tracking system.

  • Review of all letter drafts and associated documents for initial audit findings, final audit findings, responses to requests for review and reconsideration of audit finding and any letters drafted to address unique circumstances that present themselves in day to day audit activities. Obtains client/appropriate staff approval of letters and other communications that will be sent to provider offices where applicable.

  • Responds to provider inquiries that have been escalated from the Case Disposition Specialists or the Audit team.

  • Identifies areas for provider education and works with the functional teams to develop appropriate materials.

  • Collaborates with the IME client to continually improve processes for audit initiation, recovery of overpayments and cost avoidance projects.

  • Oversees and provides support to the MCO PI Oversight process for IME

  • Monitors budget and resource needs and creates management and client reports in conjunction with the Project Director/Account Manager and provides back up this Manager as needed.

Additional Duties:

  • Coordination Related Tasks

  • Research and develop responses for algorithm questions submitted by federal (CMS) Medicaid Contractors. Participate in Contractor calls and offer status updates as needed.

  • Maintain letter templates used in day to day PI/SUR operations and incorporate changes as indicated by the client or as business needs arise. Coordinate with the appropriate client staff to verify review and approval by legal counsel.

  • Participate in internal status updates with contractor management staff. Participate in status meetings between sub-contractors and client staff.

  • Assist with review of subcontractor letters and documents as needed prior to submission to client.

  • Review and approve algorithm recovery status report and letter statistics prior to submission to client.

  • Design, develop, review and deliver SUR and other reports to the state to support the efficient operation of the team and meet contractual requirements.

  • Research claims payment policies, provider manual, provider communications, regulations, coding guidelines and federal legislation as related to SUR audit activities.

  • Case Management System

  • Assist with review and provide input for compilation of case management system requirements as needed. Meet with client to discuss and review Business Design documents for audit and case disposition related system changes.

  • Assist in quality check of system content as it relates to SUR Financial tracking and Case Disposition audit cases.

  • Assist with quality and user acceptance testing for Case Management and other PI systems and data bases as needed.

  • PI Financial

  • Coordinate monthly meeting with client’s financial personnel to discuss PI finance related processes, issues, questions or concerns identified in day to day PI operations.

  • Review and sign void/adjustment requests submitted as a result of audit activity prior to submission to the State for review and approval.

  • Coordinate claim void/adjustment activities with fiscal agent. Develop process to address manual void/adjustment submissions and ensure proper follow up communication is obtained.

  • Communicate process flow and any process changes regarding the claim void/adjustment process to subcontractors.

  • General

  • Assist Data Analytics team by offering advice and guidance on approach for data analysis algorithms. Attend Data Analytics preparation meeting to discuss algorithm results to be presented to the State and follow up on outstanding algorithms.

  • Provide input on contract goals and achievements related to audit and case disposition activities for development of year end reporting.

  • Research and assess impact of changes orders for claims payment system or changes in legislation as it relates to the audit and case disposition team processes or policies.

Required Technical and Professional Expertise

  • Bachelor’s degree in a related field.

  • Five (5) or more years of experience in a consulting or operations environment within the health care industry,

  • Experience developing policies, procedures, processes and workflows.

  • Prior experience with health care claims, provider relations, fraud and abuse

  • Demonstrated ability to understand industry issues and problems within the Medicaid program, relate them to client’s needs, and propose appropriate solutions.

  • Excellent oral and written communication skills and outstanding presentation skills.

  • Customer focused, willingness to spend time working onsite with the client and travel occasionally for training and coordination meetings

  • Strong project management, organization and prioritization skills

  • Computer literate, with experience in Word, Excel, PowerPoint and workflow solutions

Preferred Tech and Prof Experience

  • Ability to motivate and engage a work team

  • Project manager certification; experience with Pembok and/or Lean methodologies a plus.

  • Specific experience with Medicaid and MCO program integrity is a plus.

EO Statement

IBM is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. IBM is also committed to compliance with all fair employment practices regarding citizenship and immigration status.