Review Vacancy
TitleMedicaid Eligibility Examiner 3
Occupational CategoryNo Preference
Bargaining UnitPS&T - Professional, Scientific, and Technical (PEF)
Salary RangeFrom $0 to $49488 Annually
Street Address NYS Department of Health, Office of Health Insurance Programs
Division of Eligibility and Marketplace Integration
Minimum Qualifications Candidates must be a current NYS County Department of Social Services employee with permanent competitive status and eligible for transfer in accordance with Civil Service Law. Candidates must have one (1) year or more permanent service as a Supervising Eligibility Examiner; Principal Social Welfare Examiner; Eligibility Examiner 3, or in a position where the work involves responsibility for planning, coordinating, supervising, and managing the performance and activities of income maintenance functions of the agency (Food Stamps, Temporary Assistance, Medicaid, and Screening Units);
OR
Five years of professional experience (one year of which must have included supervision of staff) performing one or more of the following six activities*, in a program that:
• Reimburses for health care services;
• Works with social services program areas;
• Determines eligibility for a consumer assisted program in a hospital/health care facility;
• Provides health care regulatory oversight; or
• Performs quality assurance and interpretation/application of standards of health care.
*Activities:
1. Determining eligibility for a health care program in which financial eligibility criteria must be met;
2. Performing utilization review, including pre-payment or post-payment review of requested health care services, prior approval or authorization activities, adjudication or pricing of claims for payment; or analysis of patterns of health care;
3. Reimbursement and financing of health care services, including rate-setting or approval, establishing capitation reimbursement methodologies, assessing fee schedule, coding constructs for medical goods and services, or applying/processing of reimbursement methodologies;
4. Performing quality assurance activities such as ensuring compliance with laws, rules, regulations, and policies.
5. Inspecting, assessing, or monitoring health care programs or facilities for certification, licensure or adherence to laws, rules, regulations, and policies; and
6. Planning, designing, developing, researching, or evaluating proposals to establish or refine programs, with ongoing responsibility for interpreting legislation or regulations, defining/describing target populations and local demographics, grant/proposal writing, or developing, reviewing, and evaluating contracts.
College study may be substituted for up to two years of the required general experience, at the rate of 15 semester credit hours equaling six months of the required experience
NOTE: Examples of non-qualifying experience include, but are not limited to: patient advocates, case managers, direct care experience (i.e., nurse, social worker, and physical therapist), clerical and data entry duties, experience in a private physician’s office, or as a billing clerk.
Preferred Qualifications:
Expertise in public health insurance programs, especially with eligibility and coverage policy issues; expertise with New York’s Medicaid, Child Health Plus (CHPlus), and Family Health Plus (FHPlus) eligibility and coverage policy issues; experience with Medicaid policy and procedures related to the Medicare Savings Program, Family Planning Benefit Program and Third Party Health Insurance; ability to work well independently and under pressure, and to meet deadlines; strong writing, verbal communication, interpersonal, and analytical skills.
Duties Description The Bureau of Quality Management and Change Control (BQMCC) oversees the change control process with MAXIMUS (contractor), working with other bureaus to assess the impact of proposed changes, identify impacts across program areas, and track all change requests. This bureau will be handling the cases that cannot be done electronically by the New York State of Health and are required to develop solutions to complicated processes. The BQMCC also conducts quality assurance on NYSOH activities to identify trends and propose necessary changes, and will oversee the call center where consumers can have questions answered.
Under the general supervision of higher level staff, the incumbent(s) will assist with the execution of the BQMCC’’s objectives geared toward ensuring quality customer service at the NYSOH contact center. Specific duties include, but are not limited to: provide supervision to paraprofessional staff; field electronic referrals from the contact center; work with appropriate staff to resolve consumer issues; conduct live monitoring and quality assurance (QA) reviews of recorded consumer calls using established QA procedures; maintain cooperative working relationships with other units, divisions, departments, and agencies to facilitate the delivery of public health insurance. May also interpret and communicate a variety of Federal and State laws and codes to implement policies, procedures and maintain compliance in the delivery of public health insurance benefits; review, sign or authorize eligibility determinations; monitor the quantity and quality of work completed by staff to ensure accuracy and adherence to procedures and instructions; identify and resolve inaccuracies; prepare, compile and organize data for various reports; may appear at judicial or administrative proceedings when required to interpret decisions; and develop and review eligibility scenarios to test new computer applications and systems.
Additional Comments Permanent appointment, full-time.
Some positions may require additional credentials or a background check to verify your identity.
Name Human Resources Management Group, RD/MEE3/NYC
Email Address resume@health.ny.gov
Address
Street Room 2217, Corning Tower
Empire State Plaza
Notes on ApplyingSubmit resume to Human Resources Management Group, RD/MEE3/NYC, Room 2217, Corning Tower Building, Empire State Plaza, Albany, New York 12237-0012, or by email to resume@health.ny.gov, or by fax to (518)473-3395 with a subject line RD/MEE3/NYC. Resume must clearly state how you meet the minimum qualifications as stated above. Vague or missing information could result in your being disqualified for consideration for these positions. Human Resource Administration employees are asked to supply a copy of their Civil Service history, which can be obtained from your Personnel/Payroll Office. Applications will be accepted until the positions are filled.