Medicaid Eligibility Examiner 4

Open to the public.

Agency New York State Department of Health
Title Medicaid Eligibility Examiner 4
Salary $59,825
Salary Grade 21
Negotiating Unit PEF/05
Location NYS Department of Health, Office of Health Insurance Programs Division of Eligibility and Marketplace Integration Albany, New York
Minimum Qualifications Six (6) years of professional experience [two (2) years of which must have included supervision of staff] performing one or more of the following six activities*, in a program that: " Reimburses for health care services; " Works with social services program areas; " Determines eligibility for a consumer assisted program; " Provides health care services; " 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 or consumer assisted 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 three (3) years of the required general experience, at the rate of 30 semester credit hours equaling one (1) year of the required experience, the remaining three (3) years experience must include two (2) years of supervision of staff.
Preferred Qualifications
Responsibilities The Division of Eligibility and Marketplace 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 (MA) program. These positions will help ensure that the process of determining MA, 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 and under general supervision of higher level staff, the incumbent will serve as supervisor of a small group of paraprofessional and/or support staff that performs a variety of duties related to accepting and processing applications for public health insurance. The incumbents will provide support for activities related to expansion and eligibility initiatives implemented through the Enrollment Center; technical assistance on eligibility policy for MA; and perform functions necessary to assume the responsibilities of the LDSS. Specific duties include but are not limited to: analyze and interpret State and Federal legislation to ensure that all mandates are being met; when applicable, contact cooperating agencies (Social Security Administration, Centers for Medicare and Medicaid, etc.) to verify client's documentation for eligibility or clarify information being supplied; based on pertinent eligibility laws, rules, and regulations, make recommendations on administering New York's public health insurance programs; act as an informal mediator in disputes between subordinate employees and applicants/clients; establish necessary criteria for determining unit performance and oversee personnel activities including but not limited to training, performance evaluations, and disciplinary actions; address specific concerns for resolution of complex applications; interact with consumers and advocates as issues arise surrounding various public health insurance programs; based on analyses of information provided by applicants, make eligibility determinations and process applications for public health insurance in difficult and/or special cases; assist with training staff and/or relevant stakeholders in response to identified needs or when new or revised regulations and procedures are introduced; provide written material, verbally explain and answer questions; provide technical assistance and direction to an assigned group of subordinate staff as well as other paraprofessional and/or support staff; assign and review work of an assigned group of subordinate staff within assigned area of responsibility; monitor the quantity and quality of work completed by staff to ensure accuracy and adherence to procedures and instructions; identify and recommend resolution of issues to supervisor; prepare, compile and organize data for various operating and management reports; assist program areas with quality improvement activities as needed.
Conditions of Employment Provisional pending exam, full-time.
Application Procedure Submit resume to Human Resources Management Group, RD/MEE4/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/MEE4/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 filled.

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

Issued January 31, 2014