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Posted : Tuesday, August 20, 2024 11:30 AM
Description of Work
**This position is exempt from the State Human Resources Act**
TELEWORK AVAILABILITY: We trust our employees to be self-motivated and successful in hybrid/remote roles; NC Department of Health and Human Services offers work from home options and variable work schedule flexibility for this position.
Division of Health Benefits employees with an approved hybrid telework schedule are currently expected to work onsite at their assigned duty station at least 4 working days per month or more as needed for business operations.
Telework options are subject to change at the discretion of management.
More information on this arrangement may be obtained at the time of interview.
This position’s duty station is assigned to 333 Six Forks Road, Raleigh, NC 27609.
Position Summary The DHHS Hearing Office adjudicates appeals of adverse determinations by various sources within the Department of Health and Human Services applying applicable State and Federal Medicaid polices and laws.
The Hearing Officers conduct reconsideration review hearings, which provide due process, and issues impartial decisions to Medicaid providers appealing adverse determinations by DHB or its vendors.
These adverse decisions can be related to the recovery of improperly paid claims to the Medicaid program and regarding Medicaid provider enrollment.
The hearing office also holds informal Medicaid provider appeals of DHB and its vendor’s recommended adverse decisions which include but are not limited to recoupment actions, termination from participation in Medicaid, prepayment terminations, suspensions of payments due to alleged credible allegations of fraud; provider enrollment denial and termination decisions made by DHB Provider Services and its vendor, and adverse actions against providers under 10A NCAC 22J.
The Hearing Office handles formal appeals regarding the transfer/discharge of residents from nursing homes, adult care homes, and family care homes; and appeals of PASRR (preadmission screening and resident review) decisions.
The Lead Hearings Officer II reports to the Chief Hearings Officer and serves as a lead to the other hearings officers.
Job Specific Responsibilities Assigned to handle any new, unusual, or particularly complex types of appeals.
Create, revise, and update Hearing Office decisional, dismissal, and scheduling templates.
Create/revise any other documents as needed and as directed by the Chief Hearings Officer (CHO).
Train new staff members and serve as acting Chief Hearing Officer in the CHO’s absence.
Assist the CHO in regularly reviewing NC Medicaid Bulletins, Coverage Policies, Medicaid or Department Implementation updates or initiatives etc.
to share and disseminate to HO staff during monthly meetings or other means as appropriate.
Provide training on the various appeals processes and procedures administered by the Hearing Office.
Participate in the Division of Aging and Adult Services’ training of new Long Term Care Ombudsmen regarding the long-term care facility transfer/discharge appeals process.
Provide overview of appeals process for DHB Program Integrity and its vendors and other entities as requested and feasible.
Provide brief overview of hearing proceedings and procedures for the parties involved.
Respond to questions from hearing participants regarding hearing procedures and process without engaging in ex-parte communication of the substantive issues involved in a case.
Coordinate scheduling of the hearing with the parties and attorneys when applicable.
Knowledge, Skills and Abilities / Competencies To receive credit for all of your work history and credentials, you must list the information on the application form.
Any information listed under the text resume section or on an attachment will not be considered for qualifying credit.
Qualified applicants must document on the application that they possess all of the following: Experience communicating effectively with internal and external stakeholders.
Working knowledge of Medicaid laws, policies, regulations, rules and statutes and the ability to properly analyze them in the context of case-specific facts and findings.
Experience analyzing large volumes of documents and summarizing complex facts and issues in clear and concise decisions.
Management Preferences: Previous and proven work experience at Division of Health Benefits/NC Medicaid.
Familiarity with relevant and current NC Medicaid operations.
Adjudication experience with Medicaid, Medicare, or similar program.
Minimum Education and Experience Requirements Some state job postings say you can qualify by an “equivalent combination of education and experience.
” If that language appears below, then you may qualify through EITHER years of education OR years of directly related experience, OR a combination of both.
See oshr.
nc.
gov/experience-guide for details.
Bachelor’s degree from an appropriately accredited institution and four (4) years of experience in administrative adjudication proceedings; or an equivalent combination of education and experience.
Degrees must be from appropriately accredited colleges or universities.
Supplemental and Contact Information The North Carolina Department of Health and Human Services is an Equal Opportunity Employer.
Pre-employment criminal background checks are required for all positions with the Division of Health Benefits (DHB).
About NC Medicaid (Division of Health Benefits) The North Carolina Department of Health and Human Services (NCDHHS) works closely with beneficiaries, health care professionals, community leaders and advocacy groups; local, state and federal entities; and other community partners vested to improve the health and safety of all North Carolinians by providing essential human services.
NCDHHS is one of the largest, most complex agencies in the state, with about 17,000 employees.
The Division of Health Benefits (DHB) within NCDHHS is committed to advancing innovative solutions that improve health, promote well-being and foster independence for all North Carolinians.
DHB manages and oversees North Carolina Medicaid, NC Medicaid Managed Care and other programs that provide access to services and supports for parents, children, seniors, people with intellectual / developmental disabilities, and behavioral health, substance use and traumatic brain injury disorders.
With a budget over $21 billion in state and federal funds per fiscal year, DHB ensures that more than 96,000 enrolled providers are reimbursed for delivering covered services to 2.
9 million beneficiaries.
Realizing the strength of DHB lies in its employees, DHB remains dedicated in its efforts to create and maintain a diverse, equitable and inclusive workplace environment.
Application Process Applicants are encouraged to apply for positions of interest, regardless of their current grade level and job classification.
A pay increase may or may not result.
Salary decisions are based on relevant education and experience, budget, and internal equity.
To be under consideration for this vacancy, all applicants must complete an online application using this link: https://www.
governmentjobs.
com/careers/northcarolina.
If multiple applications are submitted to an individual posting, only the most recent application received prior to the posting close date will be evaluated for consideration.
Due to the volume of applications received, we are unable to provide information regarding the status of your application.
To check the status of your application, please log in to your GovernmentJobs.
com account.
You will either receive a call or email to schedule an interview or an email notifying you when the job has been filled.
For technical issues with your application, please call the NeoGov Help Line at 855-524-5627.
If there are any questions about this posting other than your application status, please contact us at Medicaid.
Recruitment@dhhs.
nc.
gov.
Division of Health Benefits employees with an approved hybrid telework schedule are currently expected to work onsite at their assigned duty station at least 4 working days per month or more as needed for business operations.
Telework options are subject to change at the discretion of management.
More information on this arrangement may be obtained at the time of interview.
This position’s duty station is assigned to 333 Six Forks Road, Raleigh, NC 27609.
Position Summary The DHHS Hearing Office adjudicates appeals of adverse determinations by various sources within the Department of Health and Human Services applying applicable State and Federal Medicaid polices and laws.
The Hearing Officers conduct reconsideration review hearings, which provide due process, and issues impartial decisions to Medicaid providers appealing adverse determinations by DHB or its vendors.
These adverse decisions can be related to the recovery of improperly paid claims to the Medicaid program and regarding Medicaid provider enrollment.
The hearing office also holds informal Medicaid provider appeals of DHB and its vendor’s recommended adverse decisions which include but are not limited to recoupment actions, termination from participation in Medicaid, prepayment terminations, suspensions of payments due to alleged credible allegations of fraud; provider enrollment denial and termination decisions made by DHB Provider Services and its vendor, and adverse actions against providers under 10A NCAC 22J.
The Hearing Office handles formal appeals regarding the transfer/discharge of residents from nursing homes, adult care homes, and family care homes; and appeals of PASRR (preadmission screening and resident review) decisions.
The Lead Hearings Officer II reports to the Chief Hearings Officer and serves as a lead to the other hearings officers.
Job Specific Responsibilities Assigned to handle any new, unusual, or particularly complex types of appeals.
Create, revise, and update Hearing Office decisional, dismissal, and scheduling templates.
Create/revise any other documents as needed and as directed by the Chief Hearings Officer (CHO).
Train new staff members and serve as acting Chief Hearing Officer in the CHO’s absence.
Assist the CHO in regularly reviewing NC Medicaid Bulletins, Coverage Policies, Medicaid or Department Implementation updates or initiatives etc.
to share and disseminate to HO staff during monthly meetings or other means as appropriate.
Provide training on the various appeals processes and procedures administered by the Hearing Office.
Participate in the Division of Aging and Adult Services’ training of new Long Term Care Ombudsmen regarding the long-term care facility transfer/discharge appeals process.
Provide overview of appeals process for DHB Program Integrity and its vendors and other entities as requested and feasible.
Provide brief overview of hearing proceedings and procedures for the parties involved.
Respond to questions from hearing participants regarding hearing procedures and process without engaging in ex-parte communication of the substantive issues involved in a case.
Coordinate scheduling of the hearing with the parties and attorneys when applicable.
Knowledge, Skills and Abilities / Competencies To receive credit for all of your work history and credentials, you must list the information on the application form.
Any information listed under the text resume section or on an attachment will not be considered for qualifying credit.
Qualified applicants must document on the application that they possess all of the following: Experience communicating effectively with internal and external stakeholders.
Working knowledge of Medicaid laws, policies, regulations, rules and statutes and the ability to properly analyze them in the context of case-specific facts and findings.
Experience analyzing large volumes of documents and summarizing complex facts and issues in clear and concise decisions.
Management Preferences: Previous and proven work experience at Division of Health Benefits/NC Medicaid.
Familiarity with relevant and current NC Medicaid operations.
Adjudication experience with Medicaid, Medicare, or similar program.
Minimum Education and Experience Requirements Some state job postings say you can qualify by an “equivalent combination of education and experience.
” If that language appears below, then you may qualify through EITHER years of education OR years of directly related experience, OR a combination of both.
See oshr.
nc.
gov/experience-guide for details.
Bachelor’s degree from an appropriately accredited institution and four (4) years of experience in administrative adjudication proceedings; or an equivalent combination of education and experience.
Degrees must be from appropriately accredited colleges or universities.
Supplemental and Contact Information The North Carolina Department of Health and Human Services is an Equal Opportunity Employer.
Pre-employment criminal background checks are required for all positions with the Division of Health Benefits (DHB).
About NC Medicaid (Division of Health Benefits) The North Carolina Department of Health and Human Services (NCDHHS) works closely with beneficiaries, health care professionals, community leaders and advocacy groups; local, state and federal entities; and other community partners vested to improve the health and safety of all North Carolinians by providing essential human services.
NCDHHS is one of the largest, most complex agencies in the state, with about 17,000 employees.
The Division of Health Benefits (DHB) within NCDHHS is committed to advancing innovative solutions that improve health, promote well-being and foster independence for all North Carolinians.
DHB manages and oversees North Carolina Medicaid, NC Medicaid Managed Care and other programs that provide access to services and supports for parents, children, seniors, people with intellectual / developmental disabilities, and behavioral health, substance use and traumatic brain injury disorders.
With a budget over $21 billion in state and federal funds per fiscal year, DHB ensures that more than 96,000 enrolled providers are reimbursed for delivering covered services to 2.
9 million beneficiaries.
Realizing the strength of DHB lies in its employees, DHB remains dedicated in its efforts to create and maintain a diverse, equitable and inclusive workplace environment.
Application Process Applicants are encouraged to apply for positions of interest, regardless of their current grade level and job classification.
A pay increase may or may not result.
Salary decisions are based on relevant education and experience, budget, and internal equity.
To be under consideration for this vacancy, all applicants must complete an online application using this link: https://www.
governmentjobs.
com/careers/northcarolina.
If multiple applications are submitted to an individual posting, only the most recent application received prior to the posting close date will be evaluated for consideration.
Due to the volume of applications received, we are unable to provide information regarding the status of your application.
To check the status of your application, please log in to your GovernmentJobs.
com account.
You will either receive a call or email to schedule an interview or an email notifying you when the job has been filled.
For technical issues with your application, please call the NeoGov Help Line at 855-524-5627.
If there are any questions about this posting other than your application status, please contact us at Medicaid.
Recruitment@dhhs.
nc.
gov.
• Phone : (855) 524-5627
• Location : Wake County, NC
• Post ID: 9129384875
