Registered Nurse II

South Carolina Job Board Columbia, SC
Job Responsibilities Benefits Supplemental QuestionsAdditional

This posting is for two (2) vacant Registered Nurse II positions in Medical Service Review at the South Carolina Department of Health and Human Services. In a NON-CLINICAL setting, identifies fraud, waste, and abuse in the Medicaid Program. Conducts post-payment reviews of medical providers. Identifies and recovers excessive and inaccurate payments to providers and insure compliance with the applicable Medicaid laws, regulations, and policies. In addition, job functions and responsibilities include:

* Coordinates or schedules an informal conference to discuss review findings when requested by the provider. Coordinates pre-hearing meetings with the pertinent agency staff. Documents the informal conference or appeals process. Refers providers to other agencies or the relevant licensing boards as deemed appropriate. Determines if fraud referral warranted and coordinates with supervisor to complete referrals to Medicaid Fraud Control Unit (MFCU) at the Office of the Attorney General when fraud is suspected.

* Develops case reviews to include as determined: 1) conduct unannounced onsite visit and obtain medical records, 2) Request medical records 3) send provider/recipient survey letters 4) send provider self-audit letter, 5) request additional information or documentation or 6) make telephone calls to recipients to verify services. Reviews all information received and do a comparison review between the Medicaid paid claims, applicable Medicaid rules, regulations and policy and all documentation or information obtained. Verify appropriateness and medical necessity of services billed to Medicaid

* Learns and utilizes the current Surveillance Utilization Review System (SURS). Develops special reports in accordance with current health trends and practices utilizing nursing knowledge. Sets up and runs DCRs and focused reports as needed. Conducts evaluation and analysis of medical/dental/other provider statistical profiles and detail claims reports generated by SURS reporting system. The first line review of data includes analysis and evaluation of exception criteria and profile reports as well as generating reports of paid claims data.

* Coordinates case actions with supervisor, program area staff and a consultant when indicated. Completes provider notifications of results/findings letters. Identifies and describes the provider's aberrant billing pattern/billing errors within the letter and on the Detailed Claims Report, cites and/or includes in the initial findings packet, the policy which validates the errors and make provider recommendations to prevent the improper billing from occurring in the future. Sends educational letters as appropriate. Monitors case progression at 15 day and 35 day intervals and respond to providers as necessary in timely manner.

* Evaluates paid claims data and determine the following:

1) Patterns of practice and adherence to Medicaid program policy and procedures;

2) Researches information and make decisions utilizing nursing knowledge and expertise in evaluating health delivery patterns of individual providers and specialties;

3) Uses appropriate methodology to conduct comparison studies, focus reviews, and random sampling , review universe of claims, self-audit, line by line sample or random sampling.

Minimum and Additional Requirements:A Bachelor of Science in Nursing degree; or a diploma in nursing and two (2) years of related nursing experience; or an associate's degree in nursing and four (4) years of related nursing experience. (Graduation from an accredited school of nursing.)

Must have and maintain a valid driver's license.

NECESSARY SPECIAL REQUIREMENT: Current licensure by the State of South Carolina Board of Nursing as a Registered Nurse. Multi state/Compact Licensure is honored as well.

Additional Requirements:

Sitting or standing for long periods of time.

Lifting requirements 35 lbs.

Preferred Qualifications:

* Considerable knowledge of contemporary health care diagnosis and standard methods of treatment and therapy.

* Thorough knowledge of health care trends and practices. Nursing expertise in order to conduct comprehensive reviews of medical services.

* Ability to communicate effectively.

* The ability to multi-task within time frames and prioritize cases utilizing effective time management skills.

* Possess and apply computer proficiency and knowledge of Microsoft Excel and Word. Must be able to perform web-based software functions (pull documents from online database, run data reports, update documents, etc.).

Additional Comments:

Please complete the State application to include all current and previous work history and education. A resume will not be accepted nor reviewed to determine if an applicant has met the qualifications for the position. Supplemental questions are considered part of your official application for qualification purposes. All applicants must apply online. All correspondence from the Office of Human Resources will be through electronic mail.

This position is located in Medical Service Review.