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Job Details

Product Manager Medicaid Audit and Compliance

Company name
Navitus Health Solutions

Appleton, WI

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Product Manager, Medicaid Audit and Compliance

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Navitus Health Solutions




Wisconsin (WI)

Position type:


Job Summary:

The Medicaid Product Manager (MPM) will be responsible for providing regulatory support for the Navitus Medicaid program. The Product Manager (MPM) will facilitate efforts to develop, and implement various Medicaid process changes according to the requirements defined by the Center for Medicare and Medicaid Services (CMS) and each State regulating entity. The MPM is responsible for reviewing and acting upon all CMS and State guidance related to these functions, including technical guidance as well as business process-related guidance. The MPM must work closely with all key functional areas that administer certain Medicaid functions, including but not limited to Implementation, Formulary Administration, Provider Services, Clinical and Client Services departments.

Job Responsibilities:

Develops and maintains deep subject matter expertise related to CMS and State Medicaid requirements for provider materials, formulary / PDL, coverage determinations, grievances and appeals, customer care and pharmacy helpdesk, third party liability, and regulatory reporting.

Serves as the primary facilitator, liaison and/or leader for Medicaid regulatory audits. Responsible for the collection of and oversight of all audit related deliverables and follow up actions.

Provides oversight for issue resolution. Engages the Program Manager with all non-compliance related issues and/or when obstacles arise. Drafts and leads the execution of performance improvement plans or corrective action plans to address. Leads compliance efforts including State, CMS audits and client delegation audits.

Facilitates and oversees implementation, and maintenance of Medicaid functional processes for all Managed Medicaid clients. Develops the necessary project plans and leads projects that enhance the Medicaid operational infrastructure.

Participates in state sponsored meetings as requested and disseminates information throughout Navitus.

Monitors CMS and State regulations, guidance, and system changes. Ensures the Medicaid functions meet all regulatory requirements.

Responsible for operational oversight of the Navitus Managed Medicaid product line. Provides direct functional support for required reporting and provider/member materials. Provides support for other Navitus departments as needed.

Provides product support for client implementations. Provides subject matter expert support to Navitus Client and Clinical Services Executives representing the client.

Develops and maintain product documentation, including training materials. Assists the Program Manager in reviewing and managing updates to State contracts, ensuring content is in line with agreed upon services and regulations.

Accountable for ensuring that policies and procedures (internal controls) are in place to provide reasonable assurance the company assets are protected.

Develop and continually evaluate Government Program Operations functions, while monitoring work product measure/targets including turn-around times and accuracy.

Other duties as assigned

Company info

Navitus Health Solutions
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