MMIS Project Manager - Albany, NY - 24 Months - # K18071/180756

New York State’s Medicaid claims processing system, eMedNY, processes more than 250 million eligibility and prior authorization transactions, 450 million claims and payments in excess of $45 billion annually for New York Medicaid providers. The system supports statewide eligibility verification, claims processing and the New York Medicaid website. Additionally, the call center handles and receives nearly a million telephone calls a year from Medicaid providers, and the claims processing unit performs digital imaging and data conversion of paper documents. The critical systems, including eligibility verification, service authorization and pharmacy claims processing, are provided on a 24x7 basis. More than four million recipients receive health services through this program, with more than 75,000 participating healthcare providers (although about 150,000 are enrolled) in providing their services. Also, there are over 8,400 system users.

Reporting to the Director of the Bureau of eMedNY, assist in the oversight and direction of the operation and evolution of the New York State Medicaid Management Information System, eMedNY, for the Department of Health. As the Third Party Liability (TPL) Team Lead, duties include acting as ongoing liaison with the contractor (CSC), other state agencies, local districts, providers and federal representatives. In addition, provide organizational coordination and assistance as required to facilitate the implementation of Medicaid initiatives. Specific duties include:

•  Develop and maintain the TPL Team organization to support ongoing operational and evolution requirements within eMedNY, including developing systems requirements for budget initiatives, and to maintain and ensure the accuracy of the eMedNY TPL Data Repository, which is used for eligibility verifications and for the processing of claims.


•  Work collaboratively to interpret Medicaid policy vis-à-vis systems functionality, and participate in the development of DOH Medicaid initiatives.


•  Establish priorities and timetables for multiple systems initiatives.


•  Work collaboratively to identify and resolve systems problems and issues; assure that ongoing eMedNY operations and evolution functions are performing efficiently.


•  Oversee, direct and coordinate work efforts of CSC contractor staff as well as eMedNY TPL staff.


•  Provide leadership and direction for support activities such as audit and fraud detection.


•  Report to and provide support to DOH management on Medicaid and eMedNY TPL issues.


•  Make presentations to DOH management and other project stakeholder organizations on eMedNY TPL activities.


•  Lead in the design, development and implementation of activities necessary to maintain DOH support functions with other state agencies, other federal agencies and the provider community; work with DOH Policy and WMS systems staff to implement new projects in eMedNY, troubleshooting and enhancing system performance.


•  Provide systems support to LDSSs in correcting erroneously entered data, and provide Medicare entitlement verifications through access to the ‘State On-Line Query’ (SOLQ) system, which allows authorized users to access Social Security Administration (SSA) records.


•  Ensure that authorized TPL staff have been given the capability to change and/or void TPL data on-line when determined appropriate, and assist LDSSs in addressing MOBIUS Reports and how specific reports are to be handled, and assist in LDSS knowledge transfer sessions.


•  Correspond with CMS as needed to resolve discrepancies in data and resolve Buy-in related problems.