Medicaid Utilization Review Analyst - DMS

Description

DEDICATED TO STRENGTHENING THE HEALTH, SAFETY, AND INDEPENDENCE OF IDAHOANS

*THIS ANNOUNCEMENT WILL BE OPEN UNTIL FILLED. APPLICANTS ARE ENCOURAGED TO APPLY AS SOON AS POSSIBLE TO BE CONSIDERED.*

Do you have an interest in making a difference for Idaho's vulnerable population by helping to ensure Medicaid dollars are spent on services they need? Do you have strong analytical and critical thinking skills? Then this job may be for you. The Division of Management Services is hiring a Medicaid Utilization Review Analyst at our  Boise and Coeur d'Alene locations.   This position is instrumental in protecting the integrity of the Medicaid program. By joining our team, you will have the opportunity to help identify and deter fraud, waste and abuse in the Medicaid program. As an analyst, you will play a crucial role in conducting preliminary investigations by reviewing claims data and medical records, reviewing provider billing practices, conducting provider and participant interviews, and ensuring that Medicaid services are billed and paid in accordance with Medicaid rules and regulations. This position will communicate findings and provide program education to Medicaid providers through written and oral communication, recovering identified overpayments, assessing civil monetary penalties and taking other administrative actions when warranted. 

This position may be eligible for telework after successful completion of probation and necessary training.

The successful applicant will be required to complete a criminal history background investigation. Employment is dependent upon satisfactory results of the investigation. 

BENEFITS:

BEST RETIREMENT AVAILABLE IN THE NATION 

We have one of the Nation's best state retirement systems (PERSI) that offers a lifetime benefit. 

OTHER EXCELLENT BENEFITS

• 11 paid holidays
• Generous vacation and sick leave accrual beginning as soon as you start 
• Paid parental leave
• Medical, dental, vision insurance - incredible rates!(full-time/30+ hours per week)
• PERSI Choice 401(k)
• Deferred compensation plan
• Life insurance
• Short and long-term disability insurance
• Student Loan Forgiveness
• Wellness programs
• Employee Assistance Program (EAP)
• Flexible Spending Accounts (FSA) 
• Wide variety of training opportunities
• Some positions offer flexible hours and/or telecommuting

EXAMPLE OF DUTIES:

• Analyzes claims data and reports to identify Medicaid provider and participant utilization patterns that may indicate program abuse. 
• Reviews claims data, medical records and rules and regulations to ensure services were billed appropriately and in accordance with rules and regulations. 
• Conducts participant and provider telephone and in-person interviews to gather information on which to base decisions. 
• Conducts on-site reviews at provider locations, documenting evidence and findings. 
• Meets by phone or in-person with Medicaid providers to discuss findings. 
• Writes reports and sends notices of findings that are clear, concise and legally defensible. 
• Recommends and participates in implementation of policies and procedures for monitoring program utilization. 
• Confers with professional medical consultants concerning appropriateness and quality of medical goods and services provided to Medicaid participants. 
• Uses analytical and critical thinking skills and professional judgment in determining if providers are in compliance with Medicaid rules and regulations.
  

MINIMUM QUALIFICATIONS:

You must possess all the minimum qualifications below to pass the exam for this position. Please make sure your resume or work history supports your meeting the minimum qualifications for this position. Failure to do this may disqualify you from being considered for this position. It is highly recommended to attach a one-page cover letter to your application to demonstrate how you meet the requirements below.

• Good knowledge of medical terminology, 

  medical diagnostic and procedural terms, common medical payment procedural codes used in Current Procedural Terminology Fourth Edition (CPT-4), and other nationally recognized coding references. Typically gained by completion of college level courses covering items A-C above or a seminar or training for CPT-4/ICD OR at least one year of work experience using the above resources.
• Good knowledge of data processing systems as used in program monitoring and management information processes. Typically gained by completion of coursework/training regarding data processing systems and their use OR at least six months of work experience working with the above type data processing systems. 
• Experience recognizing patterns of medical assistance billing that suggest fraud, abuse, over-utilization, child abuse, and claims processing problems. Typically gained by at least six months of work experience in a medical or insurance office with responsibility for reviewing or processing claims that included recognizing problems such as: patterns of abuse; fraud; incomplete information; improper coding etc.
• Experience compiling, analyzing, and interpreting statistical data, and developing recommendations. Typically gained by successful completion of coursework and/or training covering statistics AND at least six months of work experience that required both verbal and written communications of findings to both internal and external entities. 
• Experience conducting interviews to obtain facts for cases. Typically gained by at least six months of work experience conducting interviews for investigations to solicit facts, record information, and determine eligibility or an appropriate course of action based on findings. Types of qualifying experience could include a background in credit collection, law enforcement, financial institutions, or social service programs or services. Experience as an office/administrative support staff conducting informal day-to-day interviews is not in-depth enough to qualify. Experience conducting employment interviews is typically non-qualifying. Experience being interviewed, e.g. to obtain employment, does not qualify.
• Experience preparing recommendations and writing interview/investigative reports. Typically gained by at least six months experience preparing recommendations and writing interview/investigative reports.

Below is preferred experience. It is not required for the position but applicants with this experience may receive consideration over other applicants.

• Some knowledge of in-depth interviewing techniques and procedures. Typically gained through college coursework or workshop/seminar that discussed interviewing techniques and procedures in detail and was the focus of the coursework or workshop/seminar. 
• Experience working in Medicaid programs with demonstrated knowledge of Medicaid regulations and administrative requirements. Typically gained by working at least one year for a state Medicaid agency or working for a Medicaid provider in a position that required Medicaid knowledge. 

Learn About a Career with DHW

***PLEASE NOTE: application assistance is not available after the business hours listed below, on the weekends, or on holidays and you must apply before 4:59 pm on the closing date. When applying, use CHROME as your browser to avoid complications.

If you have questions, please contact us at:

Email is the quickest way to get an answer to your questions.

(answered Monday through Friday during business hours MST)

EMAIL: [email protected] 
PHONE: (208) 334-0681

EEO/ADA/Veteran:

The State of Idaho is committed to providing equal employment opportunities and prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on their race, color, religion, political affiliation or belief, sex, national origin, genetics, or any other status protected under applicable federal, state, or local laws.

The State of Idaho is committed to access and reasonable accommodations for individuals with disabilities, auxiliary aids and services are available upon request. If you require an accommodation at any step in our recruitment process, you are encouraged to contact (208) 334-2263 (TTY/TTD: 711), or email [email protected].

Preference may be given to veterans who qualify under state and federal laws and regulations.