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[New Wave]

General Duties/Responsibilities:

The incumbents will perform various pre-payment review functions in the Medicaid program through the electronic prior approval and reference file systems. These include reviewing prior approval requests for durable medical equipment, private duty nursing and physician services to determine if the service falls within the scope of coverage of the Medicaid program and if the service is appropriate for the particular individual’s medical needs. This function requires the use of professional medical judgment in the examination of the proposed treatment plan or equipment purchase for the patient and professional written and telephone communication with outside stakeholders. The positions involve utilizing national standards for procedure and diagnosis coding, reviewing appropriate combinations of medical services, and identifying methods to prevent fraud and abuse. Hours are normal business hours with minimal, if any, travel required.

Preferred Qualifications:

Experience in rehabilitation, home care, medical coding and automated healthcare systems; knowledge of laws, rules, regulations and policies relating to the Medicaid program; excellent interpersonal, communication, writing, analytical and computer skills; ability to work independently as well as part of a team; and ability to organize and prioritize.

Minimum Qualifications:

Possession of a license and registration as Registered Professional Nurse in NYS AND one of the following:
• Two years of experience performing utilization reviews, claims adjudication, reviews of requests for medical services, medical review and/or investigations of fraud and abuse for third-party payers/designees or government entities or surveillance/monitoring of entities licensed by or contracted by state, local and federal agencies; OR
• Bachelor’s Degree in Nursing and two years of clinical or administrative experience in a medical facility.

Foward resumes to ec@nwpusa.com