Medicaid Eligibility Examiner 1

Open to Local County Department of Social Services Employees Only

  • Hiring Rate: $32,653
  • Grade: 9
  • Location: NYS Department of Health - Office of Health Insurance Programs, Division of Health Reform and Health Insurance Exchange Integration, Albany, New York

Responsibilities:

The Division of Health Reform and Health Insurance Exchange Integration in the Office of Health Insurance Programs (OHIP), Department of Health is looking to fill a position that will focus on assuming some of the functions currently performed by the Local Departments of Social Services (LDSS) for the Medicaid program. This position 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. The Department has begun planning for the centralization of the eligibility and enrollment function and this position will be used to support the next phase of assuming the responsibilities of the LDSS.

Within the Division of Health Reform and Health Insurance Exchange Integration, the incumbent 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:

  • 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 obtains 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.

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 directly;
    • 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;
    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 evaluation contracts; AND
  • Candidates must be a current employee of a NYS County with permanent status.
  • College study may be substituted for up to one year of the required general experience, at the rate of 15 semester credit hours equaling six months of the required experience.

Preferred Qualifications:

  • Expertise with New York's Medicaid, CHPlus, and FH Plus eligibility and coverage policy issues;
  • Experience with Medicaid policy and procedures related to the Medicare Savings Program, Family Planning Benefit Program and Third Party Health Insurance;
  • Expertise in public health insurance programs; especially with eligibility and coverage policy issues;
  • Ability to function independently and as part of a team; and
  • Ability to work well under pressure and meet deadlines.

Application procedure:

Submit resume to Division of Health Reform and Health Insurance Exchange Integration,One Commerce Plaza Room 826, MEE 1, Corning Tower, Empire State Plaza, Albany NY 12237, or by e-mail to DHRHIEI@health.state.ny.us or by fax to (518) 473-2804. Please use the subject line MEE 1.

Submit resumes by:

Recruitment Closed

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