Health and Human Resources Specialist, Senior - Bureau for Medical Services - Kanawha Co.

Nature of Work

Administers programs within the Office of Program Integrity focused on the identification and recovery of overpayments through vendors contracted to conduct audits on behalf of the agency. Serves as subject matter expert to team members reviewing records of billings, client treatment records, and narrative recordings to determine if utilization of Medicaid services conforms to proper billing practices and program guidelines and identify audit opportunities. Perform on-site reviews of Medicaid providers from a programmatic standpoint to determine accuracy of claims submitted, documentation requirements being met, medical necessity criteria and adherence to Medicaid policy. Review new and modified federal and state Medicaid regulations and make recommendations regarding audit activities that may be needed as a result of regulatory changes. Review Medicaid policies and reimbursement methodology in order to make recommendations for improving the clarity, consistency or enforceability of agency policy. Communicate both orally and in writing with representatives of the medical provider community; administrative, medical professional staff in state government agencies and private organizations regarding Medicaid policies and audits. Other related duties as assigned.

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Minimum Qualifications

Training:Bachelor's Degree from a regionally accredited four-year college or university.

Substitution:Additional experience as described below may be substituted for the required training on a year-for-year basis.

Experience:Four years full-time, equivalent part-time paid or volunteer experience in a technical or program area that is related to the area of employment.

Substitution:Post-graduate education in a field related to the technical or program area may be substituted for the required experience on the basis of fifteen semester hours for one year of experience.

Other Information

Three (3) years of full-time or equivalent part-time paid experience in the Health and Human Resources series may substitute for the required training and experience. "