The SC Department of Health and Human Services is searching for a Registered Nurse to join our Office of Medical Service Review. This position identifies waste, fraud and abuse in the Medicaid program by performing reviews on providers of Medicaid services. Key duties will include:
- Identifies and recovers excessive and inaccurate payments to providers and insure compliance with the applicable Medicaid laws, regulations and policies.
- Performs the reviews under limited supervision in conformance with established Program Integrity policies and procedures.
- Provides research on fraud trends, Best Practices and complete analysis of cost savings ideas submitted by peers/self. Assists peers with prep of investigative reports, to include but not limited to, obtaining needed info from MCOs on fraud referral cases.
- Coordinates or schedules an informal conference to discuss review findings when requested by the provider. Coordinates pre-hearing meeting with the pertinent agency staff. Documents the informal conference or appeals process.
- Refers providers to other agencies or the relevant licensing board as deemed appropriate.
- Determines if fraud referrals are warranted and coordinates with supervisor to complete referrals to MFCU (Office of the Attorney General) when fraud is suspected.
- Develops case reviews.
- Reviews all information received and do a comparison review between the Medicaid paid claims, applicable Medicaid rules, regulations and policy and all documentation or information obtained.
- Verifies appropriateness and medical necessity of services billed to Medicaid. Learns and utilizes the current SURS system.
- Develops special reports in accordance with current health trends and practices utilizing nursing knowledge. Sets up and runs DCRs and focused reports as needed.
- Conducts evaluation and analysis of medical/dental/other provider statistical profiles and detail claims reports generated by SURS reporting system. Reviews of data includes analysis and evaluation of exception criteria and profile reports, as well as generating reports of paid claims data.
- Coordinates case actions with supervisor, program area staff and a consultant when indicated. Complete provider notifications of results/findings letters.
- Identifies and prescribes the provider's aberrant billing pattern/billing errors within the letter and on the Detailed Claims Report, cite and/or include in the initial findings packet, the policy which validates the errors and make provider recommendations to prevent the improper billing from occurring in the future. Sends educational letters as appropriate. Monitors case progression at 15 day and 35 day intervals and respond to providers as necessary in a timely manner. Evaluates Paid Claims data.
Minimum and Additional Requirements:
A bachelor's degree and three (3) years of experience in nursing or an associate's degree and five (5) years of experience in nursing.
Must have and maintain a valid driver's license.
Additional Requirements:
Sitting or standing for long periods of time.
Preferred Qualifications:
Must have current licensure as a Registered Nurse by the SC Board of Nursing.
Graduation from an accredited school of nursing.
Three (3) years of experience in nursing, health, or a medical related specialty.
Considerable knowledge of contemporary health care diagnosis and standard methods of treatment and therapy.
Thorough knowledge of health care trends and practices; nursing expertise in order to conduct comprehensive reviews of medical services.
Ability to communicate effectively.
Working knowledge of a personal computer.
Maintain a current SC Registered Nurse License.
Will work under limited supervision in conformance with established policies and procedures.
Additional Comments:
Please complete the State application to include all current and previous work history and education. A resume will not be accepted nor reviewed to determine if an applicant has met the qualifications for the position. Supplemental questions are considered part of your official application for qualification purposes. All applicants must apply on line. All correspondence from the Office of Human Resources will be through electronic mail.
This position is located in the Office of Medical Service Review in Columbia, SC. |
