Medicaid Utilization Review Analyst - DMS
The Department of Health and Welfare
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.
The Bureau of Compliance is searching for a self-motivated individual to investigate and ensure Medicaid provider compliance with Medicaid rules, regulations, and policies to work Monday through Friday, flexible hours between 7am and 5pm, with holidays off and the opportunity to telecommute. After completing probation there could be the opportunity to request a flexible schedule or compressed work week. We are looking for applicants in Boise. This position is instrumental in protecting the integrity of the Medicaid program. The individual will conduct preliminary investigations, audit Medicaid billings, and represent the Department as an excellent communicator with providers, in presentations, in hearings, with agencies, and with community businesses. A positive and professional image, excellent research and analytical skills, and decisiveness with the ability to communicate well are critical for this position. Some travel is required; trips can last from one day to a week. A state car is provided for travel.
The successful candidate will be required to pass a background investigation and an expanded reference check.
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:
- Reviews and analyzes Medicaid Management Information System (MMIS) reports to identify utilization patterns and individual providers or clients who may be abusing the program.
- Develops cases by interviewing providers and clients, conducts on-site reviews, and documents evidence.
- Meets with providers to discuss findings.
- Recommends and participates in development and 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 clients.
- Makes and assists with presentations to internal units, provider groups, and Medicaid staff on Utilization Review policy and procedures.
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.
- 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.
1-3 above typically requires completion of college level courses covering those items or a seminar or training for CPT-4/ICD OR at least one year of work experience using the above resources.
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.
- 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.
- 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 OR at least one year of work experience that required both verbal and written communications of findings to both internal and external entities.
- Providing verbal and written communication of findings to both internal and external entities. 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 OR at least one year of work experience that required both verbal and written communications of findings to both internal and external entities.
***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: dhwjobs@dhw.idaho.gov
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 ada.coordinator@dhr.idaho.gov.
Preference may be given to veterans who qualify under state and federal laws and regulations.