Nurse Reviewer

Summary of Need:

Mission statement of OHIP:

The overall mission is to optimize the health of Medicaid members by wisely using all available resources. The location is responsible for administering New York's Medicaid budget by collaborating with stakeholders across the health care industry including other state agencies, local and federal government agencies, providers, members, and community-based organizations. They are also responsible for implementation of major initiatives including Medicaid Redesign, the Affordable Care Act, and State Administration of Medicaid.

Division functions:

Division of Medical and Dental Directors

The Division is responsible for the prior approval and pended claims functions for durable medical equipment, private duty nursing, hearing aids, vision care, and dental. The Division also manages the prior approval process for out-of-state nursing home placements, high tech radiology, the Center for Operational Excellence, and the Medical Indemnity Fund. They perform Medicaid operational functions including prior authorization for supplies and services, review of pended claims for pricing, timeliness of submissions and adherence to Medicaid claims submission policy, prior authorization for Fee for Service (FFS) Medicaid beneficiaries seeking admission to skilled nursing facilities out of state, and operation of a call center to answer inquiries from providers and members about prior approval.

Position Description:

The Division of Medical and Dental Directors, Bureau of Medical Review:

The Nurse Reviewer will be assigned to the Medical Prior Approval Unit, responsible for review of prior authorization and prior approval of private duty nursing services, durable medical equipment, prosthetics, orthotics, medical supplies, and hearing aids. The staff person will perform prior approval review functions to determine if services requested are medically necessary, fall within the scope of coverage of the Medicaid program, and if the service is appropriate for the member's medical needs. This function requires the use of professional medical judgment in the examination of submitted prior approval requests, paid claims history, and provider submitted documentation to substantiate the medical necessity for the requested services. The position involves utilizing national standards for procedure and diagnosis coding, reviewing appropriate combinations of medical services, and identifying methods to prevent fraud and abuse. This position is required to maintain adequate staffing so that the Unit can continue to meet review timeframes specified in regulation (reviews competed within 21 days).

Additional Skill Level, Experience or Other Requirements:

• Current licensed as registered professional nurse in NYS.
• Three years post licensure professional nursing experience, at least two years which must have been in a licensed healthcare facility. (School nursing or medical office experience does not apply.).
• Experience in prior approval of medical supplies/equipment/services or experience in examination of medical records, documentation, and proposed treatment plans for medical necessity.
• Experience with national standards for procedure and diagnosis coding is preferred.
• Previous claims experience preferred but not required.
• Nursing home surveillance/case management experience is preferred but not required.
• Experience with Microsoft Office.
• Proficient in the use of standard office technology.
• Ability to be flexible, innovative, and work in a team environment.
  
  

Work Hours:

8:30am-4:30pm/9am-5pm (Flexible) (37.5 hrs per week)

Schedule may require weekends and some holidays. It will be discussed during the interview.

Contract Length: Up to 2 years.

Equiliem Healthcare specializes in staffing clinical, non-clinical, and allied personnel. We excel in all levels, disciplines, and specialties within the healthcare spectrum. Our projects range from short to long term local and travel assignments. Equiliem has been recognized as a certified small business enterprise. In addition, we are proud that we have earned the prestigious Joint Commission accreditation for staffing firms and have been awarded Best in Staffing 4 years running by our employees and client partners.

Benefits offered to our workers include the following:

• Medical Insurance
• Vision & Dental insurance
• Life Insurance
• 401K
• Commuter Benefits
• Employee Discounts & Rewards
• Payroll Payment Options