YOUR EXPERIENCE COUNTS - Under a recent change to the rules, an applicant's relevant experience now counts towards formal education degrees referenced in the posting See Per 405.1.

18 Months of additional relevant experience = Associate's degree

36 Months of additional relevant experience = Bachelor's degree

54 Months of additional relevant experience = Master's degree

*See total compensation information at the bottom of announcement.

The State of New Hampshire, Department of Health and Human Services, Division of Medicaid Services has a full time vacancy for Medicaid Medical Services Nurse Manager.

SUMMARY:

Leads clinical programs for Medicaid service delivery, clinical strategy, and regulatory compliance. Determines medical necessity for Medicaid services requests received on behalf of fee for service members requiring prior authorization in accordance with NH Medicaid administrative rules. Provides time limited case management for members needing coordination of benefits and services. Assists the Medical Services Unit Administrator by managing and overseeing clinical areas of the Medicaid Care Management contract including compliance and performance measures. Evaluates relevant regulation, legislation, statewide licensing requirements and other standards to ensure programmatic alignment. Completes clinical documentation reviews, as necessary.

RESPONSIBILITIES:

Leads emerging clinical programs by developing operational standards, evaluation and monitoring plans, and strategies to implement clinical criteria. Reviews claims and other administrative data to make recommendations to Medicaid leadership team on program development.

Evaluates requests for prior authorization received on behalf of fee for service Medicaid members and determines whether medical necessity criteria are met. Initiates contacts with members, physicians, and other key providers for additional medical documentation in order to make necessary determinations. Represents the Medicaid program at scheduled administrative hearings if a member chooses to appeal a decision when the Medical Services Unit Administrator is not available. Requests system changes as required to update prior authorization or claims processing operations.

Oversees the standards and implementation of treatment plans, care plans, and other similar clinical tools across Medicaid programs, provider, and vendors to ensure consistency and alignment where appropriate in support of provider experience, policy implementation, and program compliance. Assists with management and oversight of assigned clinical services to assure contract compliance by the Health plans. Works with the Medical Services Unit Administrator to develop a contract compliance plan including deliverables and due dates.

Develops, coordinates and evaluates comprehensive treatment plans for assigned fee for services members through dialogue with the individual member, the member’s family, other State agencies and treatment providers to assure appropriate treatment regimens are in place. Communicates with discharge planners, social services, physicians, nursing staff and facility case manager to coordinate services in conjunction with the case management plan.

Liaises with staff in Office of Legal Services, Bureau of Quality and Program Integrity, Division of Long-Term Services and Supports, Bureau for Mental Health Services, and other key teams to share relevant program, legislative, and regulatory information that will shape delivery and definition of Medicaid services.

Leads cross-program clinical forums to align Medicaid services with broader program offerings across the Department and increase efficiency of program delivery. Provides education, training & support to clients, providers, district offices, and other professionals, regarding Medicaid Rules and department processes and policies.

Responds to inquiries from state officials, customers, staff, providers and public or private organizations regarding Medicaid clinical policies and operational protocols.

Supervises the Program Planning and Review Specialist, Medical Services consultant, and the Program Specialist.

MINIMUM QUALIFICATIONS:

Education: Master's degree from an accredited institute of higher education with major study in nursing.

Experience: Six years of experience as a Registered Nurse, four years of which must have been in a management level position involving administrative or supervisory duties concerned with program administration, program planning and evaluation, business management or related management experience.

OR

Education: Bachelor's degree from an accredited institute of higher education with major study in nursing.

Experience: Seven years of experience as a Registered Nurse, four years of which must have been in a management level position involving administrative or supervisory duties concerned with program administration, program planning and evaluation, business management or related management experience.

License/Certification: Current licensure as a Registered Nurse in New Hampshire. Must be eligible to hold a valid New Hampshire driver’s license and/or have access to transportation for use in statewide travel.

DISCLAIMER:

The supplemental job description lists the essential functions of the position and is not intended to include every job duty and responsibility specific to the position. An employee may be required to perform other related duties not listed on the supplemental job description provided that such duties are characteristic of that job title.

For further information please contact Vernon Clough, Administrator IV, Vernon.L.Clough@DHHS.NH.GOV, 603-271-9423.

*TOTAL COMPENSATION INFORMATION

The State of NH total compensation package features an outstanding set of employee benefits, including:

HMO or POS Medical and Prescription Drug Benefits:

The actual value of State-paid health benefits is based on the employee's union status, and employee per pay period health benefit contributions will vary depending on the type of plan selected.

Value of State's share of Employee's Retirement: 13.85% of pay

Other Benefits:

o Dental Plan at minimal cost for employees and their families ($500-$1800 value)

o Flexible Spending healthcare and childcare reimbursement accounts

o State defined benefit retirement plan and Deferred Compensation 457(b) plan

o Work/life balance flexible schedules, paid holidays and generous leave plan

o $50,000 state-paid life insurance plus additional low cost group life insurance

o Incentive-based Wellness Program (ability to earn up to $500)

Want the specifics? Explore the Benefits of State Employment on our website:

EOE

TDD Access: Relay NH 1-800-735-2964