What are the responsibilities and job description for the Program Specialist position at WV Department of Human Services?
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Nature of Work
Under general supervision, this position performs work at the full-performance level.
This position is responsible for:
- Coordinating and resolving Medicaid members’ fair hearings by analyzing policy, provisions, and regulations to make decisions on multiple levels and types of appeals.
- Investigating, coordinating, and preparing all state fair hearings for all services within the entire Bureau for Medical Services.
- Working on filings with CMS for State Plan Amendments.
- Performing document search and reviews as needed for discovery, and State Plan Amendment preparation for signing authorities, including Commissioner, Cabinet Secretary, and Governor.
- Assisting 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 of Draft Desk Review decisions prepared by unit secretary.
- Performing research of Medicaid Policy Manual provisions and/or federal regulations.
- Working with contractors to ensure regulations, provisions, and policy are being followed when authorizing procedures, tests, etc.
- Overseeing correct claims payments, prior authorization, reconsideration requests, denials, etc.
- Receiving and processing FOIA requests; gather responsive documents from BMS staff; prepare documents for review by BMS attorneys; compile final documents and correspondence to complete FOIA process.
- Accessing and navigating 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.
- Creating databases for tracking purposes and maintain these as well as all paper and electronic files related to the Legal Unit.
- Drafting Document Desk Reviews decisions on behalf of the Commissioner to affirm or reverse denials.
Perform other duties as assigned.
Minimum Qualifications
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.
Job Type: Full-time
Pay: $32,862.00 - $56,373.00 per year
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Employee assistance program
- Employee discount
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Professional development assistance
- Retirement plan
- Tuition reimbursement
- Vision insurance
Work Location: In person
Salary : $32,862 - $56,373
