Women (and/or) minorities may be under-represented in this position and are encouraged to apply.
To be considered for any DPHHS Agency position, applicants must complete and submit their application online, as well as upload any required application materials. Successful applicant(s) are required to successfully pass all DPHHS specific background check(s) relevant to each position.
Materials Required of Applicants:
(To be considered in this pool, please submit the following)
Professional References: Please provide 3 professional references, work relation, and contact number.
(Please type responses in a Word document and attach to application. HELPFUL HINT: When attaching a document, you much check the “relevant document” box to ensure your attachments are uploading correctly to the specific application. Please do not attach more than requested. If you have more than 25 attachments in the system you will need to email these to: email@example.com. Failure to attach the required material will conclude in an incomplete application. You must also keep those relevant boxes checked once you submit your application; if you uncheck the box with an active application it will delete the attachment.)
This position identifies and investigates potential provider fraud, abuse and waste of Montana Medicaid and Healthy Montana Kids (HMK) programs. Key responsibilities include: Interprets state and federal policies, Medicaid State Plan, and Administrative Rules of Montana; 2) Interviews providers to verify or gather additional case information; and 3) Provides evidence and testimony for administrative reviews and fair hearings.
Major Duties or Responsibilities:
Identifies potential provider fraud through review of medical claims data, complaint referrals, application of rules, healthcare coding practices, and fraud detection software.
Reviews provider billing practices, multiple computer systems, and Montana Medicaid Information System (MMIS) to investigate medical claims data and compliance with state and federal laws.
Analyzes provider data and identifies erroneous or questionable billing practices.
Interviews providers to verify or gather additional case information.
Interprets state and federal policies, Medicaid State Plan, and Administrative Rules of Montana.
Provides evidence and testimony for administrative reviews and fair hearings.
Determines and calculates overpayment/underpayment and collects overpayment.
Refers fraud cases to other state or federal agencies to coordinate and support continued case investigations.
Shares information with providers regarding rules, regulations, Medicaid Program Manual and coding rules, as related to billing, fraud, and abuse.
Responds or refers inquiries from recipients, providers, and other agencies regarding policy issues, Medicaid or HMK coverage and eligibility.
Recommends to agency staff the removal of ambiguous wording or inconsistencies from provider notices, program manuals, etc.
Communicates with fiscal staff to identify system errors or other issues.
Presents review findings to small groups.
Shares case information and evaluates review plans with supervisor.
Enters case data, correspondence, and case progress into tracking system.
Physical and Environmental Demands:
Typical office environment with keyboarding responsibilities. Occasional travel with advance notice.
Knowledge, Skills and Abilities:
Required for the first day of work:
Knowledge of Medicaid rules, medical claims processing, medical terminology and coding principles and practices.
Knowledge of Health Information Portability and Accountability Act (HIPPA) compliance.
Knowledge of reviewing, investigation, and research.
Excellent written and verbal communication skills.
Ability to provide presentations to small groups.
Ability to perform math calculations.
Analytical and critical thinking skills.
Ability to operate personal computer and general office equipment as necessary to complete essential functions, including using spreadsheets, word processing, database, email, internet, and other computer programs.
Required Minimum Education and Experience:
Bachelor’s degree in health sciences, health information, accounting, business, or social sciences related field.
Two years experience with medical claims, medical coding, or medical review of services.
Other combinations of related education and experience may be considered on a case-by-case basis.
Preferred coding certification through American Health Information Management Association (AHIMA) or American Academy of Professional Coder (AAPC).
Applicant Pool Statement: If another department vacancy occurs in this job title within six months, the same applicant pool may be used for the selection.
Training Assignment: This agency may use a training assignment. Employees in training assignments may be paid below the base pay established by the agency pay rules. Conditions of the training assignment will be stated in writing at the time of hire.
Salary: $ 15.61 - 19.51 Hourly
Benefits Package Eligibility: Health Insurance, Paid Leave & Holidays, Retirement Plan
Number of Openings: 1
Employee Status: Regular
Shift: Day Job
Travel: Yes, 5 % of the Time
Primary Location: Helena
Agency: Department of Public Health & Human Services
Union: Montana Federation of Public Employees
Bargaining Unit: 019 - MFPE-DPHHS-Quality Assurance
Posting Date: Sep 18, 2019, 12:25:28 PM
Closing Date (based on your computer's timezone): Ongoing
Required Application Materials: Cover Letter, Resume, References
Contact Name: Department of Public Health and Human Services | Contact Email: firstname.lastname@example.org | Contact Phone: 406-444-3136