Physical Therapist

Job Description

Title: Physical Therapists

Department: Department of Health (DOH)

Office: Office of Health Insurance Programs (OHIP)

Division: Division of Medical and Dental Directors (DMDD)

Location: One Commerce Plaza, Albany, NY 12260

Mission statement of OHIP :

The overall mission of the Office of Health Insurance Programs is to optimize the health of Medicaid members by wisely using all available resources. OHIP is responsible for administering New York's Medicaid budget (approximately $65B for 2018) by collaborating with stakeholders across the health care industry including other state agencies, local and federal government agencies, providers, members, and community-based organizations. OHIP is also responsible for implementation of major initiatives including Medicaid Redesign, the Affordable Care Act, and State Administration of Medicaid.

Division functions :

Division of Medical and Dental Directors (DMDD)

The Division is responsible for the prior approval and pended claims functions for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS), private duty nursing, hearing aids, vision care, and dental. The Division also manages the prior approval process for out-of-state nursing home placements, high tech radiology, the Center for Operational Excellence, and the Medical Indemnity Fund. The Bureau of Medical Review, within the Division of Medical and Dental Directors, performs Medicaid operational functions including prior authorization for supplies and services, review of pended claims for pricing, timeliness of submissions and adherence to Medicaid claims submission policy, prior authorization for Fee for Service (FFS) Medicaid members seeking admission to skilled nursing facilities out of state, and operation of a call center to answer inquiries from providers and members about prior approval.

Position Description :

• Conduct comprehensive review of DMEPOS requests for Medicaid members to determine if the service falls within the scope of coverage of the Medicaid Program and NYS Regulation.
• Professional clinical knowledge and judgement used to render decisions that ensure the requested item is appropriate to meet the individual's medical needs.
• Actively involved in the Fair Hearing process by providing supporting evidence in written format and represents the NYS Medicaid Prior Approval Department via telephone.
• Knowledgeable of NYCRR Title 10 and 18 regulations. Utilizes national standards for procedure and diagnosis coding, reviews appropriate combinations of medical services and is instrumental in identifying methods to prevent fraud and abuse.
• Works closely with physicians, outside stakeholders, and Medicaid members via written and telephonic correspondence.

Additional Skill Level, Experience or Other Requirements:

• Current license/registration
• Excellent oral and written skills required.
• Experience in prior approval of medical supplies/equipment/services or experience in examination of medical records, documentation, and proposed treatment plans for medical necessity
• Experience in evaluating, making recommendations, and writing medical justification for various DME
• Experience with Microsoft Office
• Willing to work weekend hours if needed
• Proficient in the use of standard office technology
• Ability to be flexible, innovative, and work in a team environment

We provide equal employment opportunity for all applicants and employees regardless of race, color, sex, gender identity, gender expression, religion, age, national origin, citizenship, disability, medical condition, family care status, marital status, domestic partner status, sexual orientation, genetic information, military/veteran status, or any other protected basis.