Medicaid Program Monitor
Salary undisclosed
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Supplemental Information
The Louisiana Department of Health is dedicated to fulfilling its mission through direct provision of quality services, the development and stimulation of services of others, and the utilization of available resources in the most effective manner.
LDH serves as a model employer for individuals with disabilities.
This position is located within the Louisiana Department of Health / Medical Vendor Administration / Program Integrity / East Baton Rouge Parish
Announcement Number: MVA/SP/200013
Cost Center: 3052010700
Position Number: 50550789
This vacancy is being announced as a Classified position and may be filled as a Job appointment, Probationary appointment, Promotional appointment or Detail to Special Duty.
(Job appointments are temporary appointments that may last up to 48 months)
AN IDEAL CANIDATE SHOULD POSESS THE FOLLLOWING COMPETENCIES:
Communicating Effectively: The ability to relay information correctly and appropriately to connect people and ideas.
Demonstrating Accountability: The ability to accept ownership for your actions, behaviors, performance, and decisions.
Demonstrating Initiative: The ability to assess information and take action independently to help the organization achieve its goals.
Demonstrating Self-Awareness: The ability to manage your personality, behavior, skills, and emotions.
Displaying Professionalism: The ability to recognize how your actions impact the perceptions of both you and your organization.
Driving Results: The ability to identify important goals and work to achieve them.
Following Policies and Procedures: The ability to comply with policies and procedures of the organization as well as State Civil Service rules, and all applicable federal and state laws.
Managing Time: The ability to control your time to increase effectiveness, efficiency, or productivity.
Thinking Critically: The ability to objectively question, analyze, interpret, and evaluate information to form a conclusion.
Using Data: The ability to use relevant and valid data to inform a recommendation for action.
NOTE REGARDING THE ADVERTISED PAY:
The actual starting salary depends on the education and experience of the selected applicant.
Please click on the below links to learn more about each job level:
State Civil Service Job Information Finder
No Civil Service test score is required in order to be considered for this vacancy.
To apply for this vacancy, click on the “Apply” link above and complete an electronic application, which can be used for this vacancy as well as future job opportunities. Applicants are responsible for checking the status of their application to determine where they are in the recruitment process. Further status message information is located under the Information section of the Current Job Opportunities page.
Shambrielle Pooler
[email protected]
LDH/HUMAN RESOURCES
BATON ROUGE, LA 70821
This organization participates in E-Verify, and for more information on E-Verify, please contact DHS at 1-888-464-4218.
Minimum Qualifications
MINIMUM QUALIFICATIONS:
A baccalaureate degree plus three years of professional level experience in administrative services, economics, public health, public relations, statistical analysis, social services, or health services.
SUBSTITUTIONS:
Six years of full-time work experience in any field may be substituted for the required baccalaureate degree.
Candidates without a baccalaureate degree may combine work experience and college credit to substitute for the baccalaureate degree as follows:
A maximum of 120 semester hours may be combined with experience to substitute for the baccalaureate degree.
30 to 59 semester hours credit will substitute for one year of experience towards the baccalaureate degree.
60 to 89 semester hours credit will substitute for two years of experience towards the baccalaureate degree.
90 to 119 semester hours credit will substitute for three years of experience towards the baccalaureate degree.
120 or more semester hours credit will substitute for four years of experience towards the baccalaureate degree.
College credit earned without obtaining a baccalaureate degree may be substituted for a maximum of four years full-time work experience towards the baccalaureate degree. Candidates with 120 or more semester hours of credit, but without a degree, must also have at least two years of full-time work experience tosubstitute for the baccalaureate degree.
Graduate training with eighteen semester hours in one or any combination of the following fields will substitute for a maximum of one year of the required experience on the basis of thirty semester hours for one year of experience: public health; counseling; social work; psychology; rehabilitation services; economics; statistics; experimental/applied statistics; business, public, or health administration.
A master's degree in the above fields will substitute for one year of the required experience.
A Juris Doctorate will substitute for one year of the required experience.
Graduate training with less than a Ph.D. will substitute for a maximum of one year of experience.
A Ph.D. in the above fields will substitute for two years of the required experience.
Advanced degrees will substitute for a maximum of two years of the required experience.
NOTE:
Any college hours or degree must be from an accredited college or university.
Job Concepts
Function of Work:
To perform advanced research, analyses, and/or policy management activities for Medicaid programs.
Level of Work:
Advanced.
Supervision Received:
Broad from a Medicaid Program Supervisor or above.
Supervision Exercised:
None.
Location of Work:
Department of Health and Hospitals, Medical Vendor Administration.
Job Distinctions:
Differs from Medicaid Program Specialist 2 by the presence of advanced research, analysis and policy management responsibility.
Differs from Medicaid Program Supervisor by the absence of supervisory responsibility.
Examples of Work
Receives, reviews and completes beneficiary fraud, waste, and abuse investigations related to Medicaid/LaCHIP eligibility determinations.
Conducts audits of eligibility enrollment applications; prepares reports on results of each audit. A thorough review of financial and non-financial eligibility factors as applicable to state and federal rules and regulations will be completed per enrollee.
Contact with the enrollee will be made and all calls recorded.
Searches all available data systems for financial and non-financial data confirmation. A comprehensive case review will be conducted and findings properly documented, provide applicable policy used in the determination, and to detail corrective action(s) as necessary.
Ensures all beneficiaries are provided with a written notification of any corrective actions affecting the original Medicaid/LaCHIP eligibility determination explaining the reason(s) for the corrective action and citing the applicable Medicaid /LaCHIP policy reference.
Responsible for proper documentation of activity as it relates to the review in the Beneficiary's Case Record.
Responsible for ensuring all timelines are adhered to and continues to be responsible for the corrective action(s) until completed.
Maintain the Medicaid Beneficiary Fraud Unit general email account, track and respond to all
inquiries received or assigned timely.
Triage all inquiries and complaints received to determine if the complaint is beneficiary related, its risk factor and assign or refer to the proper department for review.
Assist with assigning and maintaining record of beneficiary fraud, waste and abuse referrals for investigation, maintain findings and results on each fraud referral received within the centralized tracking system.
Maintain and assists with up-to-date reporting statistics and data for unit reports.
Responsible for tracking and notifying management of any trends that are a direct cause of or contributing factor to errors that come to light during the review process or while tracking all cases received for review.
Refer applicable cases to the Office of Attorney General, or any other legal body as deemed
appropriate.
Prepare a written summary report with all relevant background facts and supporting
evidence on the case and any legal authorities.
Provide any assistance needed to the legal authority and may be called upon as a witness to a case once it proceeds to trial, even after, if the incumbent vacates this position.
Complete special projects as directed by management that assure accurate and timely processing of initial and/or continued eligibility requests.
Maintain work assignment and gather results of review to provide statistical and data for unit reports.
Assist and/or complete reviews as needed with agency responses to requests/complaints from providers and/or enrollees, auditors or any other agency by providing information, policy clarification, and/or directing inquirers to appropriate resources.
Cross train to provide back up to the Medicaid Beneficiary Fraud Unit and all other units within Program Integrity. Also, provide peer shadowing training when requested.
The Louisiana Department of Health is dedicated to fulfilling its mission through direct provision of quality services, the development and stimulation of services of others, and the utilization of available resources in the most effective manner.
LDH serves as a model employer for individuals with disabilities.
This position is located within the Louisiana Department of Health / Medical Vendor Administration / Program Integrity / East Baton Rouge Parish
Announcement Number: MVA/SP/200013
Cost Center: 3052010700
Position Number: 50550789
This vacancy is being announced as a Classified position and may be filled as a Job appointment, Probationary appointment, Promotional appointment or Detail to Special Duty.
(Job appointments are temporary appointments that may last up to 48 months)
AN IDEAL CANIDATE SHOULD POSESS THE FOLLLOWING COMPETENCIES:
Communicating Effectively: The ability to relay information correctly and appropriately to connect people and ideas.
Demonstrating Accountability: The ability to accept ownership for your actions, behaviors, performance, and decisions.
Demonstrating Initiative: The ability to assess information and take action independently to help the organization achieve its goals.
Demonstrating Self-Awareness: The ability to manage your personality, behavior, skills, and emotions.
Displaying Professionalism: The ability to recognize how your actions impact the perceptions of both you and your organization.
Driving Results: The ability to identify important goals and work to achieve them.
Following Policies and Procedures: The ability to comply with policies and procedures of the organization as well as State Civil Service rules, and all applicable federal and state laws.
Managing Time: The ability to control your time to increase effectiveness, efficiency, or productivity.
Thinking Critically: The ability to objectively question, analyze, interpret, and evaluate information to form a conclusion.
Using Data: The ability to use relevant and valid data to inform a recommendation for action.
NOTE REGARDING THE ADVERTISED PAY:
The actual starting salary depends on the education and experience of the selected applicant.
Please click on the below links to learn more about each job level:
State Civil Service Job Information Finder
No Civil Service test score is required in order to be considered for this vacancy.
To apply for this vacancy, click on the “Apply” link above and complete an electronic application, which can be used for this vacancy as well as future job opportunities. Applicants are responsible for checking the status of their application to determine where they are in the recruitment process. Further status message information is located under the Information section of the Current Job Opportunities page.
- Resumes WILL NOT be accepted in lieu of completed education and experience sections on your application. Applications may be rejected if incomplete.*
Shambrielle Pooler
[email protected]
LDH/HUMAN RESOURCES
BATON ROUGE, LA 70821
This organization participates in E-Verify, and for more information on E-Verify, please contact DHS at 1-888-464-4218.
Minimum Qualifications
MINIMUM QUALIFICATIONS:
A baccalaureate degree plus three years of professional level experience in administrative services, economics, public health, public relations, statistical analysis, social services, or health services.
SUBSTITUTIONS:
Six years of full-time work experience in any field may be substituted for the required baccalaureate degree.
Candidates without a baccalaureate degree may combine work experience and college credit to substitute for the baccalaureate degree as follows:
A maximum of 120 semester hours may be combined with experience to substitute for the baccalaureate degree.
30 to 59 semester hours credit will substitute for one year of experience towards the baccalaureate degree.
60 to 89 semester hours credit will substitute for two years of experience towards the baccalaureate degree.
90 to 119 semester hours credit will substitute for three years of experience towards the baccalaureate degree.
120 or more semester hours credit will substitute for four years of experience towards the baccalaureate degree.
College credit earned without obtaining a baccalaureate degree may be substituted for a maximum of four years full-time work experience towards the baccalaureate degree. Candidates with 120 or more semester hours of credit, but without a degree, must also have at least two years of full-time work experience tosubstitute for the baccalaureate degree.
Graduate training with eighteen semester hours in one or any combination of the following fields will substitute for a maximum of one year of the required experience on the basis of thirty semester hours for one year of experience: public health; counseling; social work; psychology; rehabilitation services; economics; statistics; experimental/applied statistics; business, public, or health administration.
A master's degree in the above fields will substitute for one year of the required experience.
A Juris Doctorate will substitute for one year of the required experience.
Graduate training with less than a Ph.D. will substitute for a maximum of one year of experience.
A Ph.D. in the above fields will substitute for two years of the required experience.
Advanced degrees will substitute for a maximum of two years of the required experience.
NOTE:
Any college hours or degree must be from an accredited college or university.
Job Concepts
Function of Work:
To perform advanced research, analyses, and/or policy management activities for Medicaid programs.
Level of Work:
Advanced.
Supervision Received:
Broad from a Medicaid Program Supervisor or above.
Supervision Exercised:
None.
Location of Work:
Department of Health and Hospitals, Medical Vendor Administration.
Job Distinctions:
Differs from Medicaid Program Specialist 2 by the presence of advanced research, analysis and policy management responsibility.
Differs from Medicaid Program Supervisor by the absence of supervisory responsibility.
Examples of Work
Receives, reviews and completes beneficiary fraud, waste, and abuse investigations related to Medicaid/LaCHIP eligibility determinations.
Conducts audits of eligibility enrollment applications; prepares reports on results of each audit. A thorough review of financial and non-financial eligibility factors as applicable to state and federal rules and regulations will be completed per enrollee.
Contact with the enrollee will be made and all calls recorded.
Searches all available data systems for financial and non-financial data confirmation. A comprehensive case review will be conducted and findings properly documented, provide applicable policy used in the determination, and to detail corrective action(s) as necessary.
Ensures all beneficiaries are provided with a written notification of any corrective actions affecting the original Medicaid/LaCHIP eligibility determination explaining the reason(s) for the corrective action and citing the applicable Medicaid /LaCHIP policy reference.
Responsible for proper documentation of activity as it relates to the review in the Beneficiary's Case Record.
Responsible for ensuring all timelines are adhered to and continues to be responsible for the corrective action(s) until completed.
Maintain the Medicaid Beneficiary Fraud Unit general email account, track and respond to all
inquiries received or assigned timely.
Triage all inquiries and complaints received to determine if the complaint is beneficiary related, its risk factor and assign or refer to the proper department for review.
Assist with assigning and maintaining record of beneficiary fraud, waste and abuse referrals for investigation, maintain findings and results on each fraud referral received within the centralized tracking system.
Maintain and assists with up-to-date reporting statistics and data for unit reports.
Responsible for tracking and notifying management of any trends that are a direct cause of or contributing factor to errors that come to light during the review process or while tracking all cases received for review.
Refer applicable cases to the Office of Attorney General, or any other legal body as deemed
appropriate.
Prepare a written summary report with all relevant background facts and supporting
evidence on the case and any legal authorities.
Provide any assistance needed to the legal authority and may be called upon as a witness to a case once it proceeds to trial, even after, if the incumbent vacates this position.
Complete special projects as directed by management that assure accurate and timely processing of initial and/or continued eligibility requests.
Maintain work assignment and gather results of review to provide statistical and data for unit reports.
Assist and/or complete reviews as needed with agency responses to requests/complaints from providers and/or enrollees, auditors or any other agency by providing information, policy clarification, and/or directing inquirers to appropriate resources.
Cross train to provide back up to the Medicaid Beneficiary Fraud Unit and all other units within Program Integrity. Also, provide peer shadowing training when requested.
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