Health and Human Resources Associate

4 weeks ago

Charleston, United States State of West Virginia Full time

This position is under general supervision, performs work at the full-performance level. This position reviews and evaluates payment denials to providers and prepares decisions for signature by attorney. This requires independent discretion and analysis of medical records, Medicaid procedures, policies, and federal regulation. Analyze policy to make decisions on multiple levels and types of appeals and audits. Make decisions on appeals and notify providers of these decisions. Work with contractors to authorize, deny or pay claims. Create databases for tracking purposes and maintain these databases, as well as paper and electronic files related to the legal unit. Assist AG's and BMS attorneys with research and compiling evidence for discoveries for litigation preparation. Access and navigate multiple systems such as Kepro C3, Kepro C3 Nursing homes, QNXT, ISIGHT, Ad Hoc Reports Manager, Health Pas, Health Pas-RX and Review Manager (to retrieve InterQual criteria) all used daily, to analyze claims, prior authorization requests, member hearing requests and provider denials. Research requests for FOIA discoveries and state plan amendment preparation for signing authorities, including Commissioner, Cabinet Secretary and Governor. Draft detailed document desk review decisions on behalf of the commissioner to affirm or reverse denials. Investigate, coordinate, and prepare all state fair member hearings for all services within the entire Bureau for Medical Services. Other duties as assigned.

Click The APPLY Link To Apply Online. 

 

IMPORTANT: Your eligible score will be based on information provided in your application; therefore, make sure your application is detailed and complete. You MUST complete ALL parts of the application, including the Work Experience section.

 

ATTENTION: Applicant must verify post high school education by submitting an official transcript or diploma, training or licensure earned pertaining to this position by the closing date of the posting, if not previously verified. If you are claiming Veterans preference, please submit "MEMBER 4" form and/or your VA Letter. Protecting your personal information is our highest priority.  If your official transcript, training/licensure, or Veterans documentation contains your Social Security Number and/or birthdate, please redact that information before submitting it to the Division of Personnel.

Please attach documents to the online application before submitting it. Or, you may email it to: applicantservices@wv.gov or by mail to: WV Division of Personnel, 1900 Kanawha Blvd. E., Building 3, Suite 500, Charleston, WV 25305.

This announcement is for one (1)  or more specific vacancies and only applies to the location(s) indicated. Your application will remain active for this job for one-hundred eighty (180) days or until the job is filled. Application for this job does not automatically qualify you for other positions. Be sure to submit your application for each position of interest.  To receive an email notice anytime jobs in this or other categories are posted, you may choose to complete a Job Interest Card from the slide-out menu located at the top left of our Job Opportunities page.

Training: Graduation from an accredited four-year college or university.

Substitution: Full-time or equivalent part-time paid experience in paraprofessional or responsible clerical work at a level consistent with the work performed by an Office Assistant III and which required application of state and federal laws and/or guidelines, may be substituted for the required training on a year-for-year basis.

* DETAILS OF RELATED EXPERIENCE MUST BE SHOWN IN THE WORK EXPERIENCE SECTION OF YOUR ONLINE APPLICATION*  

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