Medicaid Eligibility Examiner 1

Open to the public.

Agency New York State Department of Health
Title Medicaid Eligibility Examiner 1
Salary $32,653
Salary Grade 9
Negotiating Unit CSEA/02
Location NYS Department of Health, Office of Health Insurance Programs Division of Health Reform and Health Insurance Exchange Integration Albany, New York
Minimum Qualifications " Two 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; " Works with social services program areas; " Determines eligibility for a consumer assisted program; " 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. 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.
Preferred Qualifications
Responsibilities The Division of Health Reform and Health Insurance Exchange Integration is looking to fill multiple positions that will focus on assuming some of the functions currently performed by the Local Departments of Social Services (LDSS) for the Medicaid program. These positions will help ensure that the process of determining Medicaid, Family Health Plus (FHPlus) and Child Health Plus (CHPlus) eligibility is efficiently and effectively transitioned from the LDSS and the participating CHPlus health plans to a centralized processing unit. Within the Division the incumbents will provide support for activities related to expansion and eligibility initiatives implemented through the Enrollment Center; technical assistance on eligibility policy for Medicaid; and perform functions necessary to assume the responsibilities of the LDSS. Specific duties and responsibilities include, but are not limited to: Assisting in developing operational procedures related to centralizing Medicaid eligibility and renewal activities; reviewing documentation concerning original and continued eligibility applications; receiving applications either electronically, by mail, telephone or in person for public health insurance and obtaining additional information omitted by applicant; determining the need for further fact-finding to avoid monetary loss to the Department and Medicaid Program; issuing a client notice explaining the eligibility determinations; reviewing cases to ensure that eligibility was determined correctly; 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; preparing formal communication regarding program administration; working collaboratively with other DOH program areas to identify and discuss administrative changes, recommendations and suggestions to improve operations and solve problems; identifying the program the applicant is eligible for, i.e. Medicaid, Child Health Plus, Family Health Plus, etc.; and researching applicant status, prior history and payment history, utilizing various data storage and retrieval systems.
Conditions of Employment Provisional pending exam, full-time.
Application Procedure Submit resume to Human Resources Management Group, RD/MEE1/OPEN, Room 2217, Corning Tower Building, Empire State Plaza, Albany, New York 12237-0012, or by email to, or by fax to (518)473-3395 with a subject line RD/MEE1/OPEN. 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. Applications will be accepted until the positions are filled.
Submit resumes by Until position is filled

An affirmative action/equal opportunity employer. Women, minorities and people with disabilities are encouraged to apply.

Issued January 31, 2014