Medicaid Eligibility Verification Specialist

HRA is dedicated to fighting poverty and income inequality by providing New Yorkers in need with essential benefits such as Food Assistance and Emergency Rental Assistance.

DHS is committed to preventing and addressing homelessness in New York City by employing a variety of innovative strategies to help families and individuals successfully exit shelter and return to self-sufficiency as quickly as possible.

The Bureau of Case Integrity & Eligibility Verification’s mission is to maximize revenue generation for DSS/HRA/DHS and outside Agencies, ensure payments are categorically eligible for their respective funding streams and carry out cost avoidance projects to minimize audit disallowances.

The Office of Revenue Management and Development (ORMD) is requesting a Principal Administrative Associate II position to function as a Medicaid Eligibility Verification Specialist in its Bureau of Case Integrity and Eligibility Verification (BCIEV)/ Eligibility Verification Unit, who will:

• Review and analyze Medicaid Assistance case records and computer data to determine which cases qualify for a category that is eligible for State and Federal funding. Identify retroactive obligations that have not been claimed and to determine the effective date of adjustment for Federal and State reimbursements as established by case record entries and date of change and occurrence.

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Review of Medicaid/Family Health Plus enrollees assigned more than one Client Identification Number (CIN) and subsequently enrolled into a Managed Care Organization (MCO) under different CINs as identified by New York Office of Medicaid Inspector General (OMIG).

Follow OMIG’s specific instructions and timeframe to return the file. Also, prepare Turnaround Documents (TADS) for demographic (changes to improve the quality of clearance matches and to help prevent duplicate CIN assignments in the future.

• Review of Medicaid/Family Health Plus enrollees assigned more than one Client Identification Number (CIN) and subsequently enrolled into a Managed Care Organization (MCO) under different CINs as identified by Office of New York State Comptroller (OSC). Follow OCS’ specific instructions and timeframe to return the file. Also, prepare Turnaround Documents (TADS) for demographic changes to improve the quality of clearance matches and to help prevent duplicate CIN assignments in the future.
• Review of Medicaid (MA) recipients identified, by Finance Office through systems match, as having multiple active Client Identification Number (CIN) in an effort to end individuals’ enrollment in multiple Medicaid Managed Care plans. Prepare reports to share with MAP of which CIN should be disenrolled from Managed Care. Also prepare Turnaround Documents (TADS) for changes to improve the quality of clearance matches and to help prevent duplicate CIN assignments in the future. Adhere to tight claim deadlines.
• Review Invalid Social Security Number Validation files of Medicaid Assistance an invalid Social Security Numbers to assist with minimizing audit disallowances and minimizing fraud. Verify clients’ demographics and prepare Turnaround Documents (TADS), when applicable, to correct client demographics. Prepare reports of referrals to Investigation, Revenue and Enforcement Administration (IREA) for client call-in and suspected fraud cases.
• Keep abreast of current Federal, State and Agency policy and procedures to ensure categorical eligible payments adhere to all appropriate regulatory requirements. Assess the potential impact on claims and claim adjustments the requirements governing the various funding streams to ensure BCIEV is current and in compliance with existing funding requirements.
• Perform quality assurance for Enterprise Data Warehouse (EDW) and Medicaid Data Warehouse (MDW) queries testing and providing feedback to enhance EDW queries.
• Complete manual case lookups in response to Medicaid related press inquiries, FOIL requests, and DSS/DHS/HRA Senior staff requests, when data match results are inconclusive, to provide accurate details, case category and eligibility.
• Perform case review analysis of Agency audit findings of cases potentially claimed in an incorrect category.
• Work on numerous special projects involving other areas of the agency
• Provide back-up documentation to substantiate claims and claim adjustments submitted by Finance Office/ORMD units
• Create case records utilizing screenshots from Welfare Management System (WMS), HRA One Viewer, Systematic Alien Verification for Entitlements (SAVE), Electronic Medicaid of New York (eMedNY), Paperless Office System (POS) and other systems.

Work Location

4 World Trade Center Hours/Schedule: 9:00 am to 5:00 pm

New York City residency is generally required within 90 days of appointment. However, City Employees in certain titles who have worked for the City for 2 continuous years may also be eligible to reside in Nassau, Suffolk, Putnam, Westchester, Rockland, or Orange County. To determine if the residency requirement applies to you, please discuss with the agency representative at the time of interview.