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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 50461941 |
Description Activated On: 4/1/2026 2:36:11 PM |
Position Purpose: Describe the primary purpose of this position and how it contributes to the organization’s objectives. Example: Provides clerical and office support within the Division to ensure its operations are conducted efficiently and effectively. This position is in the headquarters of the Bureau of Data and Claims Management, Division of MMIS Operations, Eligibility, Enrollment and Capitation (EEC) Unit. The EEC Unit provides operational direction and support for Managed Care programs within the Office of Medical Assistance Programs. The EEC Unit has primary responsibility for operational procedures established for the identification and management of Managed Care enrolled populations, in addition to providing MMIS operational support across several program areas and contributing agencies. The EEC Unit serves to uphold the unit mission by participating in program integrity efforts aimed at reducing occurrences of improper payment, whether Fee-for-Service or Managed Care, within the Medicaid Management Information System (MMIS), These efforts include, but are not limited to, monitoring and maintaining the PROMISe claims processing system, with an emphasis on the PROMISe Financial and Managed Care subsystems, to assure that Medical Assistance providers are being paid in agreement with Department of Human Services regulations and policies and to assure financial transactions are accurately reported and disseminated. The EEC Unit serves as the interface for Managed Care Organizations (MCOs) and DHS systems as well as for operational issues between the Office of Income Maintenance (OIM), Bureau of Information Systems (BIS), Bureau of Managed Care Operations (BMCO), Office of Long-Term Living (OLTL), and the Office of Mental Health and Substance Abuse Services (OMHSAS). The EEC Unit serves as a liaison between the Offices/Bureaus listed above as well as Gainwell, Deloitte, and the programmers performing system coding. This unit monitors the creation and distribution of membership information. The EEC Unit provides technical assistance to Managed Care plans and other organizations within the Department. In addition, this unit also provides extensive support to the Medicaid Managed Care programs administered by OMHSAS, OLTL, programs administered by the Bureau of Fee-For-Service Programs (FFS), and Medical Assistance Transportation Program (MATP) administered by BMCO |
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Description of Duties: Describe in detail the duties and responsibilities assigned to this position. Descriptions should include the major end result of the task. Example: Types correspondence, reports, and other various documents from handwritten drafts for review and signature of the supervisor. The incumbent in this position is responsible for the following: Analyzing and evaluating output data extracted from various Managed Care membership files and reports generated from the mainframe or batch processes to detect discrepancies or anomalies and determine data integrity. Analyzing enrollment data in response to findings by a business partner or other DHS office and preparing appropriate responses. Assisting in research, evaluation, and resolution of Managed Care online and batch problems in the eCIS (electronic Client Information System) production database. Assisting with review of business requirements for system changes associated with the Office of Medical Assistance Program initiatives. Collaborating with systems analysts and application developers from BIS and Systems Contractors in the design, development, and implementation of new or changing Managed Care membership enrollment systems to support solutions for the Department and its business partners. Communicating clearly (both orally and written) complex concepts associated with OMAP. Communicating with all levels of state staff, business partners, medical providers, and federal government representatives. Completing research and special studies related to enrollments/membership data for technical or management evaluation. Conducting business meetings including devising an agenda, leading discussions, documenting follow-up items, and preparing file notes for distribution to attendees. Designing and managing the interactive forms used on the Health Choices Extranet used to relay member information to the appropriate department. Developing and distributing data files needed by the MCOs and the Enrollment Assistance Program (EAP) for their operations. Developing and maintaining databases of Managed Care membership records for use in research, analysis, and ad hoc reports. Evaluating the effect of existing and new program office initiatives on Managed Care processing logic. Identifying claims processing system related issues, communicating the issue to both program and technical staff, working with technical staff towards a resolution, and verifying that the system issue has been resolved. Interpreting policy and contract requirements necessary to perform required duties. Maintaining a general understanding of Medical Assistance. Maintaining and revising the enrollment, disenrollment, and capitation procedures and responsibilities on the Health Choices Extranet. Managing, leading, or participating in special projects, as assigned by supervisor. Participating in meetings and workgroups as requested for the establishment of policy and processes affecting Managed Care enrollments. Participating in various meetings and work groups to assist in the ongoing development and testing of existing and new systems in support of contractual requirements, Department policy, and program objectives. Participating in various technical work groups to assist in the ongoing development and testing of existing and new systems in support of contractual requirements, Department policy, and program objectives. Performing programmatic reviews to ensure the compliance of MCOs operating in the HealthChoices (HC) and Community HealthChoices (CHC) programs with established criteria for enrollment processes, as requested. Performing routine reviews of Managed Care payment data results in DHS's claims processing system and recommend changes, when applicable. Preparing supporting documentation and written evaluation of the findings of output data and recommending next steps. Proactively identifying systematic changes that could possibly lead to increased productivity for state staff or business partners. Producing and reviewing summary data and reports for use by the division, BMCO, Comptroller’s Office, and other agencies as required/requested. Providing professional and technical assistance to MCO contractors, OIM, OLTL, and other DHS departments for enrollment related issues. Providing professional and technical support in the development, review, and evaluation of the automated Managed Care enrollment/disenrollment process supported by eCIS. This requires working with users to develop or enhance system requirements. Recommending and developing workplans to ensure that system changes are implemented in a timely manner, when appropriate. Recommending systems and operational procedure changes to meet Department objectives/initiatives. Recommending systems logic and edit changes, as necessary, to initiate changes to Managed Care membership systems logic in support of contractual requirements, Department policy, and program objectives. Researching Managed Care production problems and submitting TFS Items as appropriate. Responsible for reimbursement as well as maintaining a general understanding of the PROMISe claims processing system from claims submission through back-end reporting with a focus on the functionality and systems data contained within the Financial subsystem. Reviewing and evaluating MCO and EAP contracts to determine the effect on the current Managed Care enrollment/disenrollment processes. Serving as the systems liaison to the BMCO Core Teams and other agencies to help identify and resolve DHS/MCO systems related issues. The incumbent in this position is responsible for the following: Utilizing various software packages and data applications, i.e. MS Office, in the performance of duties, which includes preparing queries and reports. When required, providing training to staff on system changes. Performing other duties as assigned. |
Decision Making: Describe the types of decisions made by the incumbent of this position and the types of decisions referred to others. Identify the problems or issues that can be resolved at the level of this position, versus those that must be referred to the supervisor. Example: In response to a customer inquiry, this work involves researching the status of an activity and preparing a formal response for the supervisor’s signature. Responsible for assisting in the making of decisions that impact policy, procedures, operational processes, or contract provisions or standards related to health care operations or MCOs. Responsible for formulating a conclusion or recommendation for the supervisor’s approval based on thorough research and review of documents and reports. Responsible for managing priority items and communicating any potential barriers to completion of other work items to supervisor. Responsible for working independently to ensure efficient and effective day-to-day operations, obtaining supervisory guidance on the most complex, sensitive, or precedent setting issues. Responsible to understand what situations require supervisor involvement/approval for completion. |
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Requirements Profile: Identify any specific experience or requirements, such as a licensure, registration, or certification, which may be necessary to perform the functions of the position. Position-specific requirements should be consistent with a Special Requirement or other criteria identified in the classification specification covering this position. Example: Experience using Java; Professional Engineer License Experience: Licenses, registrations, or certifications: 1. N/A 2. N/A 3. N/A 4. N/A 5. N/A 6. N/A |
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Essential Functions: Provide a list of essential functions for this position. Example: Transports boxes weighing up to 60 pounds.
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