What are the responsibilities and job description for the Public Health Dentist LMAP position at New York State Office of the Medicaid Inspector General?
Duties Description
The Division of Medicaid Investigations ensures the integrity of the Medicaid program by conducting prepayment claims review, investigations, recovering over payments, and implementing administrative sanctions against providers and/or recipients and can refer for criminal prosecution.
The Public Health Dentist Will Function Supporting The Dental Prepayment Claims Review And Dental Audit Team And The Dental Investigations Team Within The Bureau Of Payment Controls & Monitoring In DMI As Needed. Descriptions For Each Team Are Below:
Prepayment Claims Review and Dental Audit Team
The Incumbent Will Work As a Team Member With The Dental Hygienists To Work Within The Prepayment Claims Review System In EMedNY Which Is a Criteria-based Claims Resolution System That Selectively Suspends Payment Of a Provider’s Claims (pend) And Allows For Professional Staff The Opportunity To Review All, Or a Portion Of a Providers Claims Prior To Payment. Regulatory Authority For Prepayment Claims Review Is Contained In The New York State Codes, Rules And Regulations, Title 18 NYCRR, Part 504.8 (4)(b)(c)(d). The Prepayment Claims Review Process Is Conclusive. The Benefits Derived From The Prepayment Claims Review Process Are Unique In OMIG And The Prepayment Claims Review Function Can Be Used In The Following Ways:
A provider compliance tool monitoring all or a portion of their activity,
A tool to deter a specific activity,
A fraud detection tool,
A provider education tool,
A quality-of-care review tool.
The duties of the position include, but are not limited to:
The incumbent will function as a member of the Dental Investigations Team within the Bureau of Payment Controls & Monitoring in DMI to target and review previously paid dental service claims to detect potential fraud and abuse by dental providers. The incumbent will work as a team member with investigators and dental hygienists to help develop cases for prosecution or administrative actions based on their professional knowledge of appropriate dental care and services. Additionally, the incumbent of this position will be responsible for preparing written narratives detailing findings based on patient record reviews and history of paid Medicaid claims related to expected and accepted dental treatments.
The duties of the position include, but are not limited to:
License to practice dentistry in New York State and four years of experience in the practice of dentistry*.
Experience in the review of dental records and/or dental audits. Experience in the Insurance industry or with various insurance programs. A clear understanding of the NYS Dental Medicaid Program rules, regulations, and guidelines. Basic computer skills with the Microsoft suite (Excel, Word, etc).
Additional Comments
Permanent, Non-Competitive. There will be minimal mandatory overtime. Travel across New York State is required as needed (possibly once or twice every few months). Current licensure and registration to practice dentistry in New York State is necessary for continued employment as a Public Health Dentist. Action will be taken to remove you from your position if you fail to maintain licensure and registration.
Free parking.
NYS Offers Great Benefits Including:
We provide reasonable and religious accommodations for any part of the application and hiring process. If you have a disability or special need that requires accommodation, please send a request to RARequest@omig.ny.gov
The Division of Medicaid Investigations ensures the integrity of the Medicaid program by conducting prepayment claims review, investigations, recovering over payments, and implementing administrative sanctions against providers and/or recipients and can refer for criminal prosecution.
The Public Health Dentist Will Function Supporting The Dental Prepayment Claims Review And Dental Audit Team And The Dental Investigations Team Within The Bureau Of Payment Controls & Monitoring In DMI As Needed. Descriptions For Each Team Are Below:
Prepayment Claims Review and Dental Audit Team
The Incumbent Will Work As a Team Member With The Dental Hygienists To Work Within The Prepayment Claims Review System In EMedNY Which Is a Criteria-based Claims Resolution System That Selectively Suspends Payment Of a Provider’s Claims (pend) And Allows For Professional Staff The Opportunity To Review All, Or a Portion Of a Providers Claims Prior To Payment. Regulatory Authority For Prepayment Claims Review Is Contained In The New York State Codes, Rules And Regulations, Title 18 NYCRR, Part 504.8 (4)(b)(c)(d). The Prepayment Claims Review Process Is Conclusive. The Benefits Derived From The Prepayment Claims Review Process Are Unique In OMIG And The Prepayment Claims Review Function Can Be Used In The Following Ways:
A provider compliance tool monitoring all or a portion of their activity,
A tool to deter a specific activity,
A fraud detection tool,
A provider education tool,
A quality-of-care review tool.
The duties of the position include, but are not limited to:
- Assisting in targeting and data review.
- Performing review and processing of pended professional dental or medical claims, assuring appropriate determinations.
- Performing research and data collection to support prepayment review actions.
- Assisting in building criteria to capture and process dental claims.
- Manually reviewing treatment records for identified Dental Audits.
- Manually reviewing treatment records for identified Dental System Match and Recovery Projects.
- Utilizing professional judgment to document and critique the quality of care provided to the Medicaid patients of identified Medicaid Providers.
- Preparing Provider review summaries and referrals for action based on NYS Dental Medicaid Rules, Regulations, Policies, and Guidelines.
- Providing official expert testimony on behalf of New York State during administrative hearings and court proceedings.
- Defending the professional judgment utilized during claim reviews, system match projects, and audits of identified Medicaid Providers.
- Utilizing professional dental expertise to provide OMIG with a critique of a Provider’s practice when suspected inappropriate performance is identified.
- Providing professional expertise to OMIG staff as requested.
- Communicating orally and in writing with Dental Medicaid Providers, OMIG legal staff, independent peers, other agencies, the provider community, and their legal counsel as necessary.
- Travelling, when necessary, to examine records or documents and testify.
The incumbent will function as a member of the Dental Investigations Team within the Bureau of Payment Controls & Monitoring in DMI to target and review previously paid dental service claims to detect potential fraud and abuse by dental providers. The incumbent will work as a team member with investigators and dental hygienists to help develop cases for prosecution or administrative actions based on their professional knowledge of appropriate dental care and services. Additionally, the incumbent of this position will be responsible for preparing written narratives detailing findings based on patient record reviews and history of paid Medicaid claims related to expected and accepted dental treatments.
The duties of the position include, but are not limited to:
- Assisting in targeting and data review.
- Performing research and data collection to support dental investigations.
- Manually reviewing treatment records for identified dental Investigations.
- Utilizing professional judgment to document and critique the quality of care provided to the Medicaid patients of identified Medicaid Providers.
- Preparing Provider review summaries and referrals for action based on NYS Dental Medicaid Rules, Regulations, Policies, and Guidelines.
- Providing official expert testimony on behalf of New York State during administrative hearings and court proceedings.
- Defending the professional judgment utilized during dental investigations of identified Medicaid Providers.
- Utilizing professional dental expertise to provide OMIG with a critique of a Provider’s practice when suspected inappropriate performance is identified.
- Providing professional expertise to OMIG staff as requested.
- Communicating orally and in writing with Dental Medicaid Providers, OMIG legal staff, independent peers, other agencies, the provider community, and their legal counsel as necessary.
- Travelling, when necessary, to examine records or documents and testify.
License to practice dentistry in New York State and four years of experience in the practice of dentistry*.
- Individuals completing dental programs outside of the United States must have completed program accredited by the World Health Organization.
Experience in the review of dental records and/or dental audits. Experience in the Insurance industry or with various insurance programs. A clear understanding of the NYS Dental Medicaid Program rules, regulations, and guidelines. Basic computer skills with the Microsoft suite (Excel, Word, etc).
Additional Comments
Permanent, Non-Competitive. There will be minimal mandatory overtime. Travel across New York State is required as needed (possibly once or twice every few months). Current licensure and registration to practice dentistry in New York State is necessary for continued employment as a Public Health Dentist. Action will be taken to remove you from your position if you fail to maintain licensure and registration.
Free parking.
NYS Offers Great Benefits Including:
- Up to 13 paid holidays annually
- Up to 13 days of paid vacation annually
- Up to 5 days of personal leave annually
- Up to 13 days of paid sick leave annually
- NYS Employees’ Retirement System
- NYS Deferred Compensation
- Public Service Loan Forgiveness
- And many more…
We provide reasonable and religious accommodations for any part of the application and hiring process. If you have a disability or special need that requires accommodation, please send a request to RARequest@omig.ny.gov
Salary : $152,158
