Claims Review Specialist-25448

Job Description

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 Yorks 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:
These 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
Previous claims experience preferred but not required