Under general supervision, this position performs work at the full-performance level. Coordinate and resolve Medicaid members’ fair hearings by analyzing policy, provisions, and regulations to make decisions on multiple levels and types of appeals. Investigate, coordinate, and prepare all state fair hearings for all services within the entire Bureau for Medical Services. Investigate, coordinate, and prepare all State Fair Member Hearings for all services within the entire Bureau for Medical Services. Work on filings with CMS for State Plan Amendments. Perform document search and reviews as needed for discovery, and State Plan Amendment preparation for signing authorities, including Commissioner, Cabinet Secretary, and Governor. Assists AG’s and BMS attorneys with compiling all evidence for discoveries for litigation preparation. Pursue Third Party Liability subrogation recovery for WV Medicaid program. Review Draft Desk Review decisions prepared by unit secretary. Perform research of Medicaid Policy Manual provisions and/or federal regulations. Work with contractors to ensure regulations, provisions, and policy is being followed when authorizing procedures, tests, etc. Also oversee correct claims payments, prior authorization, reconsideration requests, denials, etc.
Receive and process FOIA requests; gather responsive documents from BMS staff; prepare documents for review by BMS attorneys; compile final documents and correspondence to complete FOIA process. Access and navigate multiple systems such as KEPRO C3, KEPRO C3 Nursing Homes, QNXT, ISIGHT, AD HOC Reports Manager, Health PAS, Health PAS-Rx, and Review Manager (to retrieve INTERQUAL Criteria), all used daily, to analyze/audit claims, prior authorization requests, member hearing requests, and provider denials. Create databases for tracking purposes and maintain these as well as all paper and electronic files related to the Legal Unit. Draft Document Desk Reviews decisions on behalf of the Commissioner to affirm or reverse denials. Perform other duties as assigned.
Click The APPLY Link To Apply Online.
IMPORTANT: Your eligibility will be based on information provided in your resume or application; therefore, make sure your resume or application is detailed and complete. You MUST complete ALL parts of the application OR upload a resume to your submission.
ATTENTION: Applicant must verify post high school education by submitting an official transcript or diploma, training or licensure earned pertaining to this position by the closing date of the posting, if not previously verified. If you are claiming Veterans preference, please submit "MEMBER 4" form and/or your VA Letter. Protecting your personal information is our highest priority. If your official transcript, training/licensure, or Veterans documentation contains your Social Security Number and/or birthdate, please redact that information before submitting it to the Division of Personnel.
Please attach documents to the online application before submitting it. Or, you may email it to: applicantservices@wv.gov or by mail to: WV Division of Personnel, 1900 Kanawha Blvd. E., Building 3, Suite 500, Charleston, WV 25305.
This announcement is for one (1) or more specific vacancies and only applies to the location(s) indicated. Your application will remain active for this job for fifteen (15) days or until the job is filled. Application for this job does not automatically qualify you for other positions. Be sure to submit your application for each position of interest. To receive an email notice anytime jobs in this or other categories are posted, you may choose to complete a Job Interest Card from the slide-out menu located at the top left of our Job Opportunities page.
Training: Graduation from an accredited four-year college or university.
Substitution: Full-time or equivalent part-time paid experience in paraprofessional or responsible clerical work at a level consistent with the work performed by an Office Assistant III and which required application of state and federal laws and/or guidelines, may be substituted for the required training on a year-for-year basis.
***The Division of Personnel uses your complete work history to qualify you for positions. Please be as detailed as possible and list all of your past employment.***
Salary : $32,862 - $56,373
