Registered Nurse, Non-Institutional (Nurse Investigator) / 60018429, 61096625

Job Responsibilities

Two (2) Positions Available

• Develop 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 7) Coordinate and correspond case actions with Managed Care Organizations (referring providers timely), 8) Coordinate and correspond cases and complaints with the Investigator 9) Coordinate, correspond and assist in Agency’s special projects (TPL, HYDE, etc.) and contractor reviews such as UPIC, RAC, etc. Review 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. Determine if fraud referral is warranted and coordinate with supervisor to complete a referral to SC Medicaid Fraud Control Unit (SCMFCU) when fraud is suspected.
• Evaluate paid claims history data and determine the following: 1) patterns of practice and adherence to Medicaid program policy and procedures; 2) research information and make decisions utilizing nursing knowledge and expertise in evaluating health delivery patterns of individual providers and specialties; 3) use appropriate methodology to conduct comparison studies, focus reviews, and random sampling , review universe of claims, self-audit, line by line sample or random sampling. Assist in evaluating the SURS algorithms used for payment analytics to determine their validity for recoupment from MCOs and/or providers. This includes researching applicable policies to confirm the accuracy and appropriateness of each algorithm and, when needed, consulting with the policy division for clarification or guidance.
• Learn and utilize the current (BIS) Business Information Systems (SAS, MMIS etc.) and SURS department. Ability to develop special reports in accordance with current health trends and practices utilizing requisite nursing/dental/professional medical knowledge. Run DCRs (detailed claims Excel report), and focused reports on paid claims data as needed in SAS. Be able to utilize SAS to identify providers with egregious billing by researching Fraud Framework. Conducts evaluation and analysis of provider statistical profiles and detail claims reports generated by SURS/SAS reporting system. Be able to research and triage Alerts in SAS Fraud Framework. 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. Assist in evaluating the SURS algorithms used for payment analytics to determine their validity for recoupment from MCOs and/or providers. This includes researching applicable policies to confirm the accuracy and appropriateness of each algorithm and, when needed, consulting with the policy division for clarification or guidance.
• Coordinates case actions with supervisor, program area staff and investigator when indicated. Identify and describe the provider's aberrant billing pattern/billing errors within the findings letter and on the Detailed claims report, cite and/or include 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. Set up AR (accounts receivable) when sending 30-day letter and track for appeal at 40-day mark. Monitors case progression at 15 day and 35-day intervals and respond to providers, as necessary. Co-ordinate cases with MCOs, UPIC, RAC and DQ when applicable. Draft 30-day letter for UPIC and send it to the provider and track for appeal prior to closing and setting up AR (Accounts receivable).
• Coordinate or schedule an informal conference to discuss review findings when requested by the provider and defend cases in fair hearing. Coordinate pre-hearing meeting with the pertinent agency staff to include Office of General Counsel and program area representative. Document the informal conference or appeals process. Co-ordinate informal meetings, Pre-hearing conferences, and appeal hearings between State, UPICs, RACs, DQ and MCOs. Refer providers to other agencies, Managed Care Organizations or the relevant licensing board as deemed appropriate.

The South Carolina Department of Health and Human Services offers an exceptional benefits package for FTE and TGE positions that includes:

• Health, Dental, Vision, Long Term Disability, and Life Insurance for Employee, Spouse, and Children
• 15 days annual (vacation) leave per year
• 15 days sick leave per year
• 13 paid holidays
• State Retirement Plan and Deferred Compensation Programs

Minimum and Additional Requirements

Graduation from an accredited school of nursing and two (2) years of clinical experience in a nursing setting.

NECESSARY SPECIAL REQUIREMENT: Current licensure by the South Carolina State Board of Nursing as a Registered Nurse.

Additional Requirements:

• Valid driver's license.
• Requires holder to drive routinely.
• Sitting or standing for long periods of time.
• Lifting requirements: 35 lbs.
• In-office role.

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.
• Must 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, upload documents in electronic case management system, etc.).
• Will work under limited supervision in conformance with established policies and procedures.
• Coordinate fraud cases with MCOs and the Attorney General's Office.

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.

The South Carolina Department of Health and Human Services is committed to providing equal employment opportunities to all applicants and does not discriminate on the basis of race, color, religion, sex (including pregnancy, childbirth or related medical conditions, including, but not limited, to lactation), national origin, age (40 or older), disability or genetic information.