New York State’s Medicaid claims processing system, eMedNY, processes more than 250 million eligibility and prior authorization transactions, 470 million claims and payments in excess of $52 billion annually for New York Medicaid providers. The system supports statewide eligibility verification, claims processing and the New York Medicaid website. Additionally, the call center handles and receives nearly a million telephone calls a year from Medicaid providers, and the claims processing unit performs digital imaging and data conversion of paper documents. The critical systems, including eligibility verification, service authorization and pharmacy claims processing, are provided on a 24x7 basis. More than five million recipients receive health services through this program, with more than 75,000 participating healthcare providers providing their services, and over 8,400 system users.
Duties
- Monitors and troubleshoot nightly Eligibility and Managed Care Enrollment 834’s reports from NYSoH
- Data Correction - Analyze, Review and Assists NYSoH/eMedNY with Data Corrections
- Single-Source- working with single source team as 834 Expert. Assisting team to implement single source of enrollment process
- Review 834 X12 processing logic /rules --> Analyze and identify the gap
- Reconciliation (Baseline reconciliation/EP/Medicaid and CHP) - Analysis of the Data Match produced by NYSoH and eMedNY and Issuers
- Writing PL/Sql queries/Procedure to extract data
- Managing and executing EP/CR's projects
- Review and fix eMedNY Client’s coverage
- Analyzing FIDA reports from Maximus
- Review daily report for Essential Plan/CHP/Medicaid and their issue
Mandatory Requirements
- Plans, organizes and integrates cross-functional information technology projects that are significant in scope and impact.
- Experience (7+ Years)
Requirements
- Bachelor’s degree.
- 60 months experience with the Title XIX Medicaid Program.
- 60 months experience with claims payment systems such as eMedNY, with special emphasis on interfaces with other systems.
- 48 months experience with TPL in a Medicaid environment and the interactions between Medicaid, Medicare and commercial insurance providers, with special emphasis on systems integration.
- 36 months experience with local district Medicaid operations and TPL procedures.
- 36 months experience supervising staff.
- 24 months experience with developing and maintaining working relationships with local districts, and/or the Medicaid provider community, other bureaus within state and federal agencies.