Albany, New York

Registered Nurse - Medical Review

Job Locations US-NY-Albany | US-NY

Posted Date 2 months ago (12/2/2022 12:10 AM)

Job ID 2022-8902

# of Openings 1

Category Customer Service/Support

Type Regular Full-Time

Practice Area Staffing Solutions Organization

Overview

Staffing Solutions Organization LLC (SSO), a wholly owned subsidiary of Public Consulting Group, is focused on delighting clients with world-class managed staffing and talent consulting services. SSO is committed to a diverse workforce, which is a reflection of our clients and the people they serve.

Responsibilities

Registered Nurse - Medical Review in Menands, NY

Item 1161

The Office of Health Insurance Programs, Bureau of Medical Review is seeking a Registered Nurse (RN) to work as a frontline prior approval reviewer for the Out of State (OOS) Approval Unit. This unit is responsible for prior authorization for Fee for Service (FFS) Medicaid members seeking admission to skilled nursing facilities out of state as well as approval for enhanced payment rates for out of state facilities seeking to provide services for NYS Medicaid members that are not available at in-state or Medicaid network providers.

Duties:
  • Reviewing the prior authorization requests for New York Medicaid individuals requiring specialized or custodial care in out of state facilities, including Medicaid eligibility files, provider enrollment files, and documentation provided to make an administrative determination of appropriateness of requested placement.
  • Track all placement requests in the Out of State Database. Reconcile all placements monthly to assure that all out of state members are being tracked by the Department.
  • Review requests for continuation of specialized care and custodial services currently being provided to Medicaid recipients in out of state facilities and make determinations regarding the continuation of care at the facility based on level of care and availability of appropriate care within New York State.
  • Assists in the facilitation of repatriation of Medicaid members to in-state nursing homes when required. Coordinate efforts with appropriate State agencies.
  • Review and make a determination for all requests for enhanced rates for Out of State requests for services not available in New York facilities.
  • For short term, out of state inpatient placements, participate in all progress and discharge conferences during the stay. Work with the facility medical staff and other state agencies for a discharge plan when goals are met at the facility. Assist with transportation arrangements and other services if needed.
  • Represent the OOS Program at interdepartmental and interdivisional meetings


Qualifications

Qualifications:
  • Bachelor's degree
  • Currently licensed as a registered professional nurse in New York State
  • Experience in home care, claims processing, prior approval of medical supplies/equipment or experience in examination of medical records, documentation, proposed treatment plans for medical necessity
  • The ability to apply clinical nursing knowledge
  • Excellent writing skills and the ability to work independently


*Employees must follow established work schedules. The usual work schedule is 37.5 hours per week, Monday through Friday. Normal work hours are 8:00 a.m. to 4:00 p.m. unless otherwise specified by the supervisor, this includes a half hour unpaid lunch break. Total work hours must equal 37.5 hours per week.

#LI-Remote

Compensation

Compensation for roles at Staffing Solutions Organization LLC (SSO) varies depending on a wide array of factors including, but not limited to, the specific office location, role, skill set, and level of experience. As required by applicable law, SSO provides the following reasonable range of compensation for this role: [compensation range here]. In addition, SSO provides a range of benefits for this role.

EEO Statement

Public Consulting Group is an Equal Opportunity Employer dedicated to celebrating diversity and intentionally creating a culture of inclusion. We believe that we work best when our employees feel empowered and accepted, and that starts by honoring each of our unique life experiences. At PCG, all aspects of employment regarding recruitment, hiring, training, promotion, compensation, benefits, transfers, layoffs, return from layoff, company-sponsored training, education, and social and recreational programs are based on merit, business needs, job requirements, and individual qualifications. We do not discriminate on the basis of race, color, religion or belief, national, social, or ethnic origin, sex, gender identity and/or expression, age, physical, mental, or sensory disability, sexual orientation, marital, civil union, or domestic partnership status, past or present military service, citizenship status, family medical history or genetic information, family or parental status, or any other status protected under federal, state, or local law. PCG will not tolerate discrimination or harassment based on any of these characteristics. PCG believes in health, equality, and prosperity for everyone so we can succeed in changing the ways the public sector, including health, education, technology and human services industries, work.

Albany, New York

Founded in 1986 and headquartered in Boston, Massachusetts, Public Consulting Group (PCG) has nearly 2,000 professionals in over 60 offices around the U.S., in Canada, and in Europe who are dedicated to delivering leading consulting approaches and technologies to public sector clients.

Who We Serve

Public Consulting Group, Inc. (PCG) is a management consulting firm that primarily serves public sector education, health, human services, and other state, county, and municipal government clients. Established in 1986 with headquarters in Boston, the firm has extensive experience in all 50 states, clients in six Canadian provinces, and a growing practice in the European Union.

 

Because PCG has dedicated itself almost exclusively to the public sector for nearly 30 years, the firm has developed a deep understanding of the legal and regulatory requirements and fiscal constraints that often dictate a public agency's ability to meet the needs of the populations it serves. We have helped numerous public sector organizations to maximize resources, make better management decisions using performance measurement techniques, improve business processes, improve federal and state compliance, and improve client outcomes. Many of PCG's nearly 2,000 employees have extensive experience and subject matter knowledge in a range of government-related topics, from child welfare, Temporary Assistance for Needy Families (TANF), Welfare to Work (WtW), and Medicaid and Medicare policy to special education, literacy and learning, and school-based health finance. PCG's current work includes more than 1,000 active contracts in more than 40 states.

 

PCG has five designated practice areas which each have a proven track record of achieving desired results for clients. The firm often combines resources from two or more practice areas to offer a multidisciplinary approach to solve a client's challenge or pursue an opportunity.

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