Fraud Manager Jobs in Reno, NV (NOW HIRING)

The Aging and Disability Services Division (ADSD) is currently recruiting for a Health Care Coordinator 1 in Reno, Nevada. This recruitment will be used to underfill positions within the Health Care Coordinator series. Advancement to the next level may occur after meeting the minimum qualifications, satisfactory performance, and with endorsement of the appointing authority. This recruitment may be used to fill current and future vacancies as they occur in the following programs: Office of Community Living (OCL) and Facility Outreach and Community Integration Services/Money Follows the Person (FOCIS/MFP). Positions assigned to the OCL Program ensure a coordinated support system to meet the needs of at-risk elderly and persons with a disability by providing case management and essential services to recipients of OCL programs statewide to facilitate community integration and avoid institutionalization. Responsibilities include case management, assessment, eligibility determination, development, implementation, and oversight of the plan of care, home visits and documentation utilizing a web-based case management software system. Positions assigned to the Facility Outreach and Community Integration Services (FOCIS) ensure a coordinated support system to meet the needs of at-risk Nevadans by connecting and facilitating community resources for recipients to avoid institutionalization. Responsibilities include care coordination, assessments, home/facility visits, and documentation utilizing an electronic system of record keeping. ADSD fosters a positive, inclusive, and diverse work environment that values innovation, teamwork, and collaboration. The mission of ADSD is to empower individuals and their support systems by providing resources for disabilities and aging - connecting Nevadans to services and improving their quality of life.

Licensure as a Social Worker or professional licensure or certification in a medical specialty applicable to the assignment.

Assess potential client needs for case management services using assessment tools to identify social service and/or medical needs; develop and implement plans of care for those determined to be eligible for services; counsel and refer clients to services and/or contract with providers for services; maintain contact with clients through home visits and telephone calls; monitor the quality and cost of services provided to clients; periodically update plans of care; submit payment authorization requests; and maintain case files. Participate in periodic reviews of facilities providing care to Medicaid eligible clients to validate and ensure adequacy of services and resident care; ensure reimbursement matches the cost of services provided; monitor nursing facility quality indicator reports; screen and assess Medicaid clients regarding discharge to community-based care; review medical records; document findings and deficiencies on appropriate forms; prepare reports of findings and participate in exit conferences; participate in independent professional reviews of providers to determine the quality of care, compliance with patient rights, and appropriateness of placement as assigned. Review health care providers and fiscal agents to ensure clients are receiving appropriate services and payment is correct for services received; ensure providers and fiscal agents are in compliance with division policies and procedures; ensure employee health, certification and training needs are appropriate and properly documented in personnel records; verify client records have appropriate documentation and that authorized services correlate with services provided; confirm termination of services were appropriately documented and mandated reporting requirements were met; provide technical assistance regarding policies and procedures; complete written documentation using appropriate format; identify areas needing improvement and review plans of correction. Process payment authorization requests from providers to ensure the requested service, treatment, equipment or supplies are medically necessary and in compliance with Medicaid criteria prior to approving or denying requests; review pertinent medical information and previous requests; evaluate medical necessity to justify payment by comparing the diagnosis and other medical information with the request; refer requests to a medical consultant for another medical opinion as necessary; render determinations in accordance with Medicaid policy and notify providers of decisions. Review records from the fiscal agent, providers, clients and computer generated reports in order to identify abuse and potential fraud and to ensure claims were paid properly by the fiscal agent; refer financial errors to the fiscal agent for adjustment of charges and refer potential cases of fraud and abuse for further investigation. Explain proper billing procedures to contract providers selected by the client; monitor the quality of care given by the provider to clients; and submit billings for services provided to the fiscal agent for payment. Perform related duties as assigned. Under direct supervision, incumbents become familiar with Medicaid policies and procedures and receive training in the range of duties described above. This is the entry level in the series and progression to the journey level may occur upon successful completion of the probationary period, meeting the minimum qualifications, and with the recommendation of the appointing authority.

General knowledge of: theories, principles, practices, and methods of social work, nursing, or a health care field applicable to program assignment; dynamics of human behavior including interpersonal relationships and social interactions; client rights and confidentiality of information; case management practices; physical, psychological and social characteristics associated with human development. Ability to: recognize basic medical and social needs; effectively interact with people of various social, cultural, economic, and educational backgrounds; communicate effectively both orally and in writing to obtain information, explain policies and procedures and persuade others to seek or accept needed services; analyze information, problems, and situations and reach logical conclusions; compose concise, logical, and grammatically correct correspondence, case narratives and reports; read and understand technical materials; assemble, analyze and report data; organize and prioritize work; work independently and as part of a team; operate a computer sufficient to enter, store and retrieve data.

The State of Nevada is an equal opportunity employer dedicated to building diverse, inclusive, and innovative work environments with employees who reflect our communities and enthusiastically serve them. All applicants are considered without regard to race, color, national origin, religion or belief, age, disability, sex, sexual orientation, gender identity or expression, pregnancy, domestic partnership, genetic information (GINA), or compensation and/or wages.

Benefits include: Health Insurance: Medical, dental, life, and disability insurance programs for employees and their dependents/family are offered through the Public Employees' Benefits Program (PEBP). Vacation: Accrual of three weeks of annual leave each year. Sick Leave: Accrual of three weeks of sick leave each year. Holidays: 12 paid holidays per year. Retirement: Participation in the Nevada Public Employees Retirement System (PERS). Employees do not contribute to Social Security but will contribute to PERS if their position is at 50% or more full-time equivalency. For more information on how PERS service may impact Social Security benefits, visit the SSA publication (Download PDF reader). Deferred Compensation: The State offers a voluntary Deferred Compensation Program. No Nevada state income tax. Public Service Loan Forgiveness: Eligible due to public sector employment. Longevity Payments Eligibility: Employees who have received a performance rating of "standard" or better and have completed eight (8) or more years of continuous service are eligible for longevity pay. Additional benefits may apply to employees covered under a Collective Bargaining Agreement (CBA), depending on their designated bargaining unit. For more information, visit the Labor Relations Unit (LRU). For more details about your rights and responsibilities as a State of Nevada employee, please review the State of Nevada Employee Handbook (PDF) (Download PDF reader). *** State Holidays The holiday schedule for State employees is established by the Legislature. The following are legal holidays: January 1.............................................. New Year's Day Third Monday in January.................. Martin Luther King, Jr.'s Birthday Third Monday in February................ Washington's Birthday Last Monday in May........................... Memorial Day June 19................................................ Juneteenth Day July 4.................................................... Independence Day First Monday in September.............. Labor Day Last Friday in October....................... Nevada Day November 11................................................ Veterans' Day Fourth Thursday in November........ Thanksgiving Day Friday following the Fourth Thursday in November...................... Family Day December 25................................................ Christmas Day When January 1, June 19, July 4, November 11, or December 25 falls on a Saturday, the preceding Friday is the observed legal holiday. If these days fall on Sunday, the following Monday is the observed holiday. Eligibility for holiday pay is covered by the provisions of NAC 284.255