Nurse Investigator New

NURSE INVESTIGATOR

State of New Hampshire

Department of Health and Human Services- Bureau of Program Integrity

Concord, NH 03301

The State of New Hampshire, Department of Health and Human Services, Bureau of Program Integrity has a full time vacancy for Nurse Investigator.

SUMMARY:

To utilize nursing knowledge to investigate and review provider programs to ensure compliance with program standards and to make recommendations for corrective actions when appropriate.

RESPONSIBILITIES:

Analyzes provider payment histories to evaluate conformance to Medicaid policies, to validate the medical appropriateness of services, to detect fraudulent or abusive billing patterns and asses the need for further case review. Refers cases to appropriate investigatory and law enforcement entities as required.

Appointed liaison for Program Integrity (PI) cases of potential fraud or abuse for various bureaus within the Department of Health and Human Services. Represents DHHS during appeals process, which requires subject matter expertise to assist lawyers and paralegals in preparation of appeals and from hearings that support review findings. Prepares reports summarizing review findings, resulting in Provider education, recoupment of payments or imposing of other sanctions. Represents the Unit in administrative appeal process.

Reviews federal and state regulations and policies and applies them to cases being reviewed. Prepares reports summarizing review findings, resulting in either provider education, possible recoupment of erroneous payments, referral to a legal entity, or imposing of other sanctions.

Interprets and applies state and federal regulations for compliance by Medicaid providers: recommends and assists with policy development and implementation resulting from PI activities. Recommends changes to the EFADS reporting system based on case development and review findings.

Develops and presents program and case information to providers as well as other State and Federal authorities. Develops clinical claims review for the specialized care areas, such as Physician services, Durable Medical Equipment, Home Base Care, Nursing Homes, etc.

Participates in team meetings to evaluate program areas, policy clarification and assists in resolving outstanding issues. Recommends appropriate rule and system changes to ensure full compliance with Federal and State Medicaid laws and regulations.

Maintains working knowledge of the State’s MMIS systems, including the EFADS and PI Case Tracking system. Ensures Medicaid providers submit medical claims in compliance with Federal and State Medicaid rules, regulations, and billing requirements.

Works with the MCO’s PI oversight liaison as needed, to ensure a full review of all aspects of a providers medical claims history.

MINIMUM QUALIFICATIONS:

YOUR EXPERIENCE COUNTS:

Each additional year of approved formal education may be substituted for one year of required work experience and/or each additional year of approved work experience may be substituted for one year of required formal education. 

Education: Graduation from a recognized nursing program.

Experience: Five years’ experience as an RN, at least two years of which shall have been in a supervisory or administrative capacity.

License/Certification: Current license as a Registered Nurse in New Hampshire. Valid driver’s license and/or access to transportation for use in statewide travel.

PREFERRED WORK TRAITS: Considerable knowledge of the theories of professional nursing. Ability to prepare factual reports. Ability to incorporate a detailed understanding of state and federal rules for the Medicaid Program. Must be willing to maintain appearance appropriate to assigned duties and responsibilities as determined by the agency appointing authority.

DISCLAIMER STATEMENT: 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 classification.