CURRENT SPECTRUM HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Spectrum Health team members only.

Job Description

Job SummaryDirectly supervises the Medicaid team including the Program Manager, CHSCS nursing staff, an administrative nurse, transportation specialist, and field service representatives. Directs the efforts of the virtual Medicare and Medicaid operations teams. Actively participates in the strategy and tactical development to profitably grow the Priority Health Government Programs strategic business unit. Identifies opportunities to improve the cost effectiveness and administrative efficiency of all Priority Health Government Programs. Develops policies, processes, and business practices of government programs, (Medicare, Medicaid, and MIChild) operations units, to minimize medical expense and optimize administrative efficiencies, and assure regulatory compliance with state and federal agencies. Coordinates the integration of all functional operations areas. Serves as liaison with the State of Michigan to ensure proactive awareness and involvement in program and regulatory changes. Determines the operational and financial impact of proposed program and/or legislative changes. Represents Priority Health with the State of Michigan Medical Services Administration, MDCH, and other external entities. Selects, coaches, and continually supports and evaluates the performance of the Government Programs staff to successfully manage the health care needs of the population.

Essential Functions

• Monitors the contract and communications, between CMS or the Michigan Department of Community Health and Priority Health Government Programs, Inc. (PHGP) to identify revisions or new requirements. Communicates these requirements to the appropriate areas within the company and facilitates timely implementation.
• Manages the preparation, policy development, and on-going changes with regard to Medicaid and MIChild contracts.
• Works with internal and external contacts to ensure timely and accurate submission of data for Medicare, Medicaid, and MIChild products.
• Coordinates Administrative Hearings with the Michigan Medicaid Tribunal and For Cause Disenrollment requests, and represent the plan at hearings, ensuring compliance with the process.
• Develops and oversees the tools and processes for submission of Medicaid member materials to the State of Michigan, ensuring timely submission and accurate tracking as to the status, including communication of final approval status to corporate communications.
• Coordinates regulatory site visits as they apply Medicaid and MIChild programs.
• Collaborates with Health Management to ensure compliance to contract requirements, assist in the identification of opportunities, and the development of processes to achieve cost savings.
• Collaborates with Provider Contracting and provide product expertise in the development of contracts and reimbursement

Qualifications

• Required Bachelor's Degree in health care or business

• 3 years of experience typically gained through skills/knowledge/abilities in managed care operations Required
• Demonstrated project management experience Required

#LI-SH

Primary Location

SITE - Priority Health - 1231 E Beltline - Grand Rapids

Department Name

PH - State Programs

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

40

Hours of Work

8 a.m. to 5 p.m.

Days Worked

Monday to Friday

Weekend Frequency

Variable weekends

Spectrum Health requires all team members to receive the COVID-19 vaccinations subject to certain exclusions based on the team member’s job category. Spectrum Health is committed to granting reasonable accommodations in accordance with applicable laws.

Accommodation Notice: If you are a qualified individual with a disability, you may request a reasonable accommodation in Spectrum Health's application process. Contact us at 616-486-SHHR (7447).

Spectrum Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, sexual orientation, veteran status, or any other legally protected

category. See more here.