NY State of Health Counsel, Bureau of Appeals
Minimum Qualifications Four years of professional experience performing one or more of the following six activities*, in a program that:
• Reimburses for health care services;
• Provides health care services directly;
• Provides health care regulatory oversight; or
• Performs quality assurance and interpretation/application of standards of health care.
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. Developing mechanisms for the reimbursement and financing of health care services, including rate-setting or approval, capitation reimbursement methodologies, fee schedule development, coding constructs for medical goods and services, or application/processing or reimbursement methodologies;
4. Administering or supervising day-to-day program operations with ongoing responsibility for budgeting, staffing, planning, or 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.
NOTE: 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.
Duties Description Within the Division of Legal Affairs, NY State of Health Counsel, Bureau of Appeals, the incumbents of these positions will supervise staff and assist with support activities related to appeals from eligibility determinations made by the NY State of Health, Health Plan Marketplace; assist with the scheduling of hearings and desk reviews; coordinate with the customer service provider regarding the processing of appeals requests; make arrangements for off-site hearings; provide technical assistance on eligibility for Medicaid, CHP, advanced premium tax credits and cost sharing reductions and other related matters, including aid to continue ; assist legal staff; and perform functions necessary to assume the responsibilities of the Local Departments of Social Services pertaining to eligibility for health insurance programs and hearings regarding eligibility determinations. Duties include: processing consumer appeals; coordinating with the customer service provider regarding appeals requests; processing requests for reconsiderations and further appeals; ensuring that appeals files are prepared and maintained; assisting the legal staff; entering changes into NY-HX to effectuate appeal determinations; uploading decisions to the HX systems; reviewing cases with respect to status, aid to continue, compliance, and related issues; handling additional evidence received at hearings and make sure that evidence is properly stored; resolving discrepancies in various data match processes; ensuring systems are operated in a manner consistent with federal and state statute and regulations; assisting in the implementation of policy and regulation changes; working collaboratively with other DOH program areas to identify and discuss administrative changes, recommendations and suggestions to improve operations and solve problems; and researching applicant status, prior history, and the status of appeals requests, utilizing various data storage and retrieval systems.
Some positions may require additional credentials or a background check to verify your identity.
Empire State Plaza
Notes on ApplyingSubmit resume to Human Resources Management Group, MEE2OPEN/15264/RD, Room 2217, Corning Tower Building, Empire State Plaza, Albany, New York 12237-0012, or by email to email@example.com, or by fax to (518)473-3395 with a subject line MEE2OPEN/15264/RD. Applications will be accepted until the positions are filled