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OMIG MEDICAL REVIEW OFFICER
The Office of Medicaid Inspector General (OMIG) Medical Review Officer is responsible for examining and analyzing Medicaid billing records, conducting compliance audits, and investigating allegations of Medicaid fraud. This position is governed by state and federal laws and agency policy.
Class Code:
C107C
Job Grade:
GS08
Special Job Requirements:
Frequent overnight in-state travel may be required.
Typical Functions:
Conducts programmatic and operational/performance compliance audits of medical providers and facilities.
Assists medical providers and facilities in developing and monitoring protocols and identifies fundamental issues and risks associated with Medicaid fraud, waste, and abuse.
Reviews medical records to ensure compliance with established criteria, policy, and regulations.
Compiles data and audit information for preparation of reports and schedules and records findings and analysis of information for future projections.
Explains adjustments and Medicaid program regulations via telephone, correspondence, and/or in-person visits, including attendance at administrative hearings.
Assists in training other medical review officers and auditors by acting as a group lead on large, complex audits and explaining auditing standards, policies, and procedures.
Performs other duties as assigned.
Knowledge, Abilities, and Skills:
Knowledge of the provider and Medicaid billing practices and procedures.
Knowledge of the principles of medical record auditing procedures.
Knowledge of Microsoft Suite software programs.
Ability to interpret and apply laws, rules and policies to specific situations.
Ability to use electronic medical record and claims information systems.
Ability to use computer software programs to produce reports and correspondence.
Ability to collaborate with and lead the work of an interdisciplinary team.
Ability to effectively communicate orally and in writing.
Ability to manage and prioritize multiple tasks and adhere to deadlines.
Minimum Qualifications:
The formal education equivalent of an associates degree in nursing; plus six years of experience in nursing, reviewing claims for medical services within a hospital, medical office/clinic, mental health entity, health plan organization or a related health care field, and/or performing medical coding, health information exchange or a related field, including one year in a leadership capacity.
OR
The formal education equivalent of a bachelors degree in nursing, social work, psychology, counseling or a health care related field; plus four years of experience in nursing, reviewing claims for medical services within a hospital, medical office/clinic, mental health entity, health plan organization or a related health care field, and/or performing medical coding, health information exchange or a related field, including one year in a leadership capacity.
Additional requirements determined by the agency for recruiting purposes require review and approval by the Office of Personnel Management.
OTHER JOB RELATED EDUCATION AND/OR EXPERIENCE MAY BE SUBSTITUTED FOR ALL OR PART OF THESE BASIC REQUIREMENTS, EXCEPT FOR CERTIFICATION OR LICENSURE REQUIREMENTS, UPON APPROVAL OF THE QUALIFICATIONS REVIEW COMMITTEE.
Required Certificates:
Must possess one or more of the following:
Licensed as a Registered Nurse (RN) or Practical Nurse (LPN).
Certified as a Professional Coder or Coding Specialist.
Registered as a Health Information Technician or Administrator.
Licensed as a Certified Social
Exempt:
E
