Claims Review Specialist
hace 5 días
Albany
Job Description JOB-19160 Claims Review Specialist-25448 Mission statement of OHIP: The overall mission of the Office of Health Insurance Programs is to optimize the health of Medicaid members by wisely using all available resources. OHIP is responsible for administering New York’s Medicaid budget (approximately $65B for 2018) by collaborating with stakeholders across the health care industry including other state agencies, local and federal government agencies, providers, members, and community-based organizations. OHIP is also responsible for implementation of major initiatives including Medicaid Redesign, the Affordable Care Act, and State Administration of Medicaid. Division functions: The Division of Medical and Dental Directors (DMDD) is responsible to support and further strengthen the ability to coordinate medical and dental policy direction across all aspects of Medicaid, including managed care, fee-for-service, and waiver programs. The DMDD Bureau of Medical Review performs Medicaid operational functions including prior authorization for durable medical equipment, medical supplies, private duty nursing services, hearing aids, and out-of-state hospital and skilled nursing facility admissions. The bureau is also responsible for the review and adjudication of Medicaid claims that pend for pricing, medical review, timeliness of submissions, and adherence to Medicaid claim submission policies. Additionally, the bureau operates a call center to answer inquiries from providers and members regarding prior approval policy and status. Position Description: The Auditor positions are located within DMDD, Bureau of Medical Review, Durable Medical Equipment, Medical Supplies Prior Approval units. These positions have multiple responsibilities including, but not limited to: • Providing clerical and administrative support to the Prior Approval Units, including the preparation, organization, and assembly of Fair Hearing packets that need to be mailed to members, representatives and providers., • Reviewing Fair Hearing packets for completeness and inclusion of all required documentation prior to distribution., • Scanning and uploading all Fair Hearing documents for processing., • Processing packages for mailing within required timeframes., • Performing medical claims pricing for medical pended claims., • Reviewing invoices, applying established pricing methodologies, and performing accurate calculations in accordance with Medicaid reimbursement rules., • Entering pricing determinations and related data into the eMedNY system with high degree of accuracy and attention to detail., • Identifying discrepancies, missing documentation, or potential billing issues and escalating appropriately., • Conducting initial and basic reviews of requests for durable medical equipment and medical supplies using established criteria., • Escalating cases that fall outside of standard criteria to clinical staff (therapists, nurses, or other designated professionals) for further review and determination., • Responding to basic inquiries from providers and members via phone and email regarding prior approval status, documentation requirements, and general policy guidance in a clear, professional and courteous manner., • Adhering to established workflows, turnaround times, and performance standards to support bureau-wide service level goals. Additional Skill Level, Experience or Other Requirements: • High School Diploma or equivalent required, • Experience with Microsoft Word and Excel, • Proficient in the use of standard office technology, • Basic knowledge of medical terminology, • Ability to be flexible, innovative, and work in a team environment, • Strong written and verbal communication skills Our extensive consultant placements cover a variety of roles, from Technical Architects and Specialists to Developers, Project Managers, Analysts, Executive Secretaries, Nurses, Dietitians, Paralegals, Computer Operators, Food Preparation Workers, and many other occupations. To date, KBI has successfully placed over 1,000 consultants across more than 100 private sector companies and public sector agencies in New York State and throughout the country. We are dedicated to recruiting candidates who consistently exceed our customers’ expectations. We provide equal employment opportunity for all applicants and employees regardless of race, color, sex, gender identity, gender expression, religion, age, national origin, citizenship, disability, medical condition, family care status, marital status, domestic partner status, sexual orientation, genetic information, military/veteran status, or any other protected basis.Established in 2005, Knowledge Builders Inc. (KBI) offers a wide range of services, including Information Technology Consulting, Administrative and Health Care Staffing solutions, Payrolling, and Call Center services to organizations of all sizes, including both private companies and governmental entities. KBI is a certified Woman-Owned Business Enterprise (WBE) recognized by New York State, New York City, and the Port Authority of New York and New Jersey.\r\n\r\nOur extensive consultant placements cover a variety of roles, from Technical Architects and Specialists to Developers, Project Managers, Analysts, Executive Secretaries, Nurses, Dietitians, Paralegals, Computer Operators, Food Preparation Workers, and many other occupations. To date, KBI has successfully placed over 1,000 consultants across more than 100 private sector companies and public sector agencies in New York State and throughout the country.\r\n\r\nWe are dedicated to recruiting candidates who consistently exceed our customers’ expectations.\r\n\r\nWe provide equal employment opportunity for all applicants and employees regardless of race, color, sex, gender identity, gender expression, religion, age, national origin, citizenship, disability, medical condition, family care status, marital status, domestic partner status, sexual orientation, genetic information, military/veteran status, or any other protected basis.