Auditors - 25910

Job Description

Title/# of Positions/Unit: 1 Auditor / Bureau of Medical Review / Pended Claims

Department: Department of Health (DOH)

Office: Office of Health Insurance Programs (OHIP)

Division: Medical and Dental Directors

Location: One Commerce Plaza, 12th Floor

Shift/Schedule: 9:00 AM to 5:00 PM

Telework Allowed Y/N: Yes

Mission statement of OHIP:

The overall mission of the Office of Health Insurance Programs is to optimize the health of Medicaid members by wisely using all available resources. OHIP is responsible for administering New York’s Medicaid budget (approximately $65B for 2018) by collaborating with stakeholders across the health care industry including other state agencies, local and federal government agencies, providers, members, and community-based organizations. OHIP is also responsible for implementation of major initiatives including Medicaid Redesign, the Affordable Care Act, and State Administration of Medicaid.

Division functions:

The Division of Medical and Dental Directors (DMDD) is responsible for supporting and further strengthening the ability to coordinate medical and dental policy direction across all aspects of Medicaid, including managed care, fee-for-service, and waiver programs.

The DMDD Bureau of Medical Review performs Medicaid operational functions including prior authorization for durable medical equipment, medical supplies, private duty nursing services, hearing aids, and out-of-state hospital and skilled nursing facility admissions. The bureau is also responsible for the review and adjudication of Medicaid claims that pend for pricing, medical review, timeliness of submissions, and adherence to Medicaid claim submission policies.

Position Description:

The Auditor position is located within DMDD, Bureau of Medical Review Pended Claims unit. This position has multiple responsibilities including, but not limited to:

• Review of medical claims according to written procedures
• Escalate issues & complex claims
• Answer phones and transfer to the appropriate staff
• Educate providers on billing processes
• Educate providers on where to locate resources
• Maintain database for tracking purposes

Data Entry

• Proficient in the use of several databases

File and maintain documents

• Fax, scan and copy documents
• Monitor incoming emails from a shared mailbox and forward to the appropriate staff
• Maintain a positive, profession demeanor always
• All other activities as may be deemed necessary
• Assist with special projects as assigned

Additional Skill Level, Experience or Other Requirements:

• High School Graduate or Equivalent
• Experience with Microsoft Word and Excel
• Proficient in the use of standard office technology
• Ability to be flexible, innovative, and work in a team environment
• Previous claims experience preferred but not required

We provide equal employment opportunity for all applicants and employees regardless of race, color, sex, gender identity, gender expression, religion, age, national origin, citizenship, disability, medical condition, family care status, marital status, domestic partner status, sexual orientation, genetic information, military/veteran status, or any other protected basis.