• Senior Medicaid Reviewer

    Job ID 2019-3289
    Job Locations
    Analyst (Business, Systems, Data)
    Regular Full-Time
  • Responsibilities

    NCI: As a Sr. Medicaid Reviewer (Medicaid Reviewer II), you will travel extensively with your team to scheduled states for Data Processing reviews.You will review and analyze Medicaid claims processing, In assuming this position, you will be a critical contributor to meeting NCI's mission: To deliver innovative, cost-effective solutions and services that enable our customers to rapidly adapt to dynamic environments.


    Highlights of Responsibilities:

    • Extensive travel (air/car) – 60-75% per year - with your team to scheduled states for Data Processing reviews. Travel will generally be Sunday through Thursday and/or Friday based on workload.  
    • Create workflow balance to ensure prepayment claims are moved timely to safe statuses, exports are updated and sent timely and accurately, and claims are not aging in the Claims Processing Systems.
    • Assist Lead Medicaid Reviewer, as assigned, to contribute to goals and objectives.
    • Consult with the Data Processing management team to create production standards to meet and exceed CMS metrics/timeliness requirements and identifies process improvements to ensure we continually meet and exceed expectations.
    • Review and analyze multiple claim processing, eligibility enrollment, and provider enrollment systems. Make an informed decision to determine if the information in all systems resulted in an accurate payment determination.
    • Support inexperienced reviewers with policy research, interpretation, and application in all review situations.
    • Independently research complex situations, arrive at an accurate conclusion, and articulate the findings to other reviewers; helping to establish consistent review practices among all reviewers.
    • Identify training needs based on questions from and support to other staff members. Suggest a training method and prepare training materials, if necessary, for the Data Processing Review Team.
    • Consult with management and stakeholders about the implication of how state and federal policies and regulations are applied in differing claims scenarios.
    • Read, interpret, and apply complex federal and state regulations and their impact to claim processing. Suggest revisions to any impacted work products or standard operating procedures as a result of changes in federal or state regulations impacting Medicaid claims payment accuracy.
    • Review all phases of a final claims and be able to determine if all phases were completed correctly.
    • Monitor Claim Payment Systems and notify management of potential problems/errors and of potential areas for improvement
    • Enter final decisions into AdvanceMed’s case tracking system.
    • Prepare responses to ad hoc questions from stakeholders and the customer after researching review processes and documentation related to reviews.
    • Complete assignments in a manner that meets or exceeds the quality assurance goal for accuracy.
    • Maintain chain of custody on all documents and follows all confidentiality and security guidelines.





    • Bachelor’s Degree and 3 years of experience, or equivalent work experience in lieu of degree
    • Minimum two (2) years of experience in medical terminology and Medicaid claims payment systems.
    • Minimum two (2) years' experience with Medicaid/CHIP data.


    Physical Requirements:


    This position requires the ability to perform the below essential functions:

    • Sitting for long periods
    • Standing for long periods
    • Ambulate throughout an office
    • Ambulate between several buildings
    • Stoop, kneel, crouch, or crawl as required
    • Repeatedly lift and carry weight up to 15 pounds
    • Travel by land or air transportation  60-75%


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