PDO Specialist

Department: Case Management

Location: Tampa, FL

Reports To: Dir, Product Operations

Develop and implement a consumer directed program and vendor oversight model geared toward continuous monitoring and oversight of the Fiscal Employer Agent (F/EA) / Fiscal Intermediary (FI) specifically related to the consumer directed/participant direction option (PDO) care model within managed long term care. Responsibilities include but not limited to: Ensures policies and processes are developed and maintained that will hold vendors to meeting or exceeding contractually required performance and service levels. Proactively identify areas of risk and implement action plans to resolve in order to maintain Contract compliance with the consumer directed option of care. Drive resolution of vendor performance that does not meet contractual performance measures or service level agreements through developing and implementing corrective action plans. Collaborates with MLTSS care management team related to over/under utilization of consumer directed services, member satisfaction, and vendor service delivery. Serves as the subject matter expert for the consumer directed model of care.

Essential Functions:

  • Develops and maintains policies and procedures for vendor management and performance based on internal and State contractual requirements.
  • Remains up-to-date with all federal and state F/EA requirements and tax forms.
  • Ensures all consumer directed and F/EA materials distributed to participants, representatives, direct service workers, and case managers are current and in accordance with the appropriate federal and state regulations.
  • Ensure all State required approvals related to the PDO are completed timely and successfully.
  • Serves as the subject matter expert on consumer directed services and provides internal support to teams including provider relations, claims management, IT and systems integration (e.g., Electronic Visit Verification), care management, quality and compliance.
  • Oversees F/EA vendor(s) to ensure accurate submission of employer forms, direct service worker training, Level II background screenings, member and provider materials, payroll, and tax forms (e.g., IRS Form 8655).
  • Ensures all PDO related reports (routine and ad-hoc) are delivered timely and accurately.
  • Identifies and defines opportunities to improve departmental results, communications and consumer directed operating efficiencies by completing detailed analysis of potential operational strengths and opportunities for improvement.
  • Additional duties as assigned.
Additional Responsibilities:
    Candidate Education:
    • Required A Bachelor's Degree in a related field counseling, social work, psychology, nursing, or related human service or human relations field
    • Required or equivalent work experience
    • Preferred Other Experience in consumer directed model of care
    Candidate Experience:
    • Required 3 years of experience in Government (State or Federal) Managed Care Health Plan work in Medicare and/or Medicaid
    • Preferred No Experience managing vendors or consumer directed services
    Candidate Skills:
    • Intermediate Ability to drive multiple projects
    • Advanced Demonstrated interpersonal/verbal communication skills
    • Advanced Ability to influence internal and external constituents
    • Intermediate Demonstrated time management and priority setting skills
    • Intermediate Other Solid understanding of Vendor Provider agreements, the oversight process, configuration and associated operational functions of vendor contracts and service level agreements
    • Intermediate Other Understanding of key corporate functional areas: product/member benefit structures, sales/marketing, member customer service, medical authorizations/claims, strong knowledge of regulatory requirements concerning Medicare and Medicaid and consumer directed model of care
    • Intermediate Other Ability to exercise good judgment under pressure and to manage a diverse and demanding workload
    Licenses and Certifications:
    A license in one of the following is required:
      Technical Skills:
      • Required Intermediate Microsoft Excel
      • Required Intermediate Microsoft Word
      • Required Intermediate Microsoft PowerPoint
      • Required Intermediate Microsoft Outlook
      • Preferred Intermediate Healthcare Management Systems (Generic)
      Languages:

        About us
        Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. WellCare is a Fortune 500 company, and in 2018, was recognized as a Fortune "World's Most Admired Company", ranking in the top five among the health insurance and managed care industry-a testament to the hard work and dedication of the company's nearly 9,000 associates who each day live WellCare's values and deliver on its mission to help its members live better, healthier lives. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.