Job summary:

Job description:

*** Very long term project; Initial PO till 6/30/2019 -  expect to go for 5+ years  *** F2F Required; reasonable expenses will be paid for f2f interview ***

Candidate must be experienced in MMIS and/or Medicaid eligibility system projects, have working knowledge of HIPAA, and have provided IV&V services for similar-sized projects with similar complexities, inter-dependencies, and coordination requirements.  Candidate will utilize industry standards and best practices in performing IV&V oversight and progress reporting activities.

Medicaid Program Integrity system has been in production since 2017 and requires CMS certification. It is anticipated that the certification will begin at the R3 Milestone Review. The backbone of the solution is Truven (now owned by IBM) DataProbe System. I  The following implementation activities were carried out to implement a comprehensive program integrity solution for Iowa:

•     Implement a Program Integrity Database Build an analytic database with claims and other data sources useful to produce algorithms and models to identify fraud, waste and abuse in Medicaid Program.
•     Develop Surveillance and Utilization Review System - Profiles by peer group that identify providers and service recipients who are statistical outliers on multiple parameters of cost, utilization, quality of care, and/or other metrics. 
•     Develop and implement custom analytics for Iowa  Custom algorithms developed to find fraud, waste and abuse for Iowa Medicaid Enterprise. 
•     Running Vulnerability Assessment - review of one to many years of data where Truven runs paid claims data through its Software as a Solution (SaaS) software, flagging claims that appear to be over-payments or billing errors and produce a report to prioritize the algorithm development.
•     Develop and Implement Provider Surveillance Reports  Reports which provide Provider Risk Scores based on their inclusion or exclusion in eight data file.
•     Validation of Encounter Data  Compare encounter data to historical FFS data by multiple measures to assess: validity, completeness and reasonableness.
•     Implement an Investigatory Case Management System

Required Skills

• 5 years Independent validation and verification program expertise.Technical & functional skills including Medicaid business & project management.
• Experience in MMIS and/or Medicaid eligibility system projects.
• Experience providing IV&V services for similar-sized projects with similar complexities, interdependencies, and coordination requirements.
• Working knowledge of HIPAA rules, policies, and procedures

Contact the recruiter working on this position:

The recruiter working on this position is Jagadishwar Rao (Team Ravi )
His/her contact number is +(1) (919) 3353915
His/her contact email is j.rao@msysinc.com

Our recruiters will be more than happy to help you to get this contract.