Health and Human Resources Specialist, Senior

West Virginia; Charleston (WV); On-site; USD 65,000 - 90,000; Full time

Job summary

West Virginia's Office of Managed Care seeks an experienced professional to oversee Medicaid program policy interpretation, service delivery, and compliance with federal and state regulations.

The role audits MCO marketing materials for CMS/DOH compliance, provides statewide technical assistance on provider and member benefits, and leads quality improvement initiatives with healthcare partners.

Qualifications

• Bachelor's degree required in a relevant field or equivalent
• Four years of related technical or program experience may substitute for training
• Three years in Health and Human Resources can substitute for required training and experience

Responsibilities

• Audit and approve MCO print, digital, social media, video, email, and website marketing materials for compliance with federal and state regulations
• Provide highly technical statewide assistance on Medicaid provider and member benefit claims
• Manage stakeholder relations and drive quality improvement across Medicaid programs
• Evaluate and recommend operational changes aligned with CMS and DOH guidance

Education

Bachelor's Degree

Job description

Under general supervision, this position performs advanced-level work within the Office of Managed Care to ensure critical health services are effectively provided to Medicaid members. This position will serve as a subject matter expert on policy interpretation, service delivery, and compliance with federal and state regulations.

This role is responsible for overseeing managed care contract deliverables, providing complex statewide technical assistance, managing stakeholder relations, and driving quality improvement across Medicaid programs. The primary function of this position is to audit and approve Managed Care Organizations' (MCOs) print, digital, social media, video, email, and website marketing materials to ensure strict compliance with federal and state regulations. This position will also provide highly technical, complex statewide technical assistance regarding Medicaid provider and member benefit claims. Assist with provider and member issues requiring Bureau for Medical Services (BMS) intervention. Evaluate operational policies and procedures to optimize service delivery, program performance, and member outcomes. Recommend operational changes aligned with CMS (Centers for Medicare & Medicaid Services) and DOHS guidance. Build and maintain positive, collaborative relationships with healthcare providers and key stakeholders who serve Medicaid members. Serve as a subject matter expert on relevant statutes, rules, and policy interpretations. Other duties and tasks as assigned.

Training

Bachelor's Degree from a regionally accredited four-year college or university.

Substitution

Additional experience as described below may be substituted for the required training on a year-for-year basis.

Experience

Four years full-time, equivalent part-time paid or volunteer experience in a technical or program area that is related to the area of employment.

Substitution

Post-graduate education in a field related to the technical or program area may be substituted for the required experience on the basis of fifteen semester hours for one year of experience.

Substitution

Three (3) years of full-time or equivalent part-time paid experience in the Health and Human Resources series may substitute for the required training and experience.