Public Consulting Group

Medicaid Registered Nurse - Medical Review

Job Locations US-NY-Albany
Posted Date 5 months ago(12/30/2021 12:12 PM)
Job ID
# of Openings
Customer Service/Support
Regular Full-Time
Practice Area
Health Services


Medicaid Registered Nurse - Medical Review in Menands, NY


Item 1331


Staffing Solutions Organization LLC (SSO), a wholly owned subsidiary of Public Consulting Group, is focused on delighting clients with world-class managed staffing and talent consulting services. SSO is committed to a diverse workforce, which is a reflection of our clients and the people they serve.



The Office of Health Insurance Programs Bureau of Medical Review is seeking a Registered Nurse (RN) to work as a frontline prior approval/pended claims reviewer. The Bureau of Medical Review is responsible for prior approval and post payment review of medical equipment and services, policy development, fraud and abuse monitoring for the New York State Medicaid System. 



·       Perform pre-payment review functions in the Bureau of Medical Review within the Prior Approval and Pended Claims Units:

·       Prior Approval – uses electronic prior approval and reference file systems to review prior approval requests for durable medical equipment, private duty nursing and physician services and determine if the service falls within the scope of coverage of the Medicaid program and if the service is appropriate for the individual’s medical needs

·       Medical Pended Claims - uses the claims processing system and other electronic references to perform pre-payment, post-service adjudication of claims that pend for medical review.

·       Provide clinical expertise to evaluating new technologies that are being considered for inclusion in Medicaid Fee Schedule


Basic Qualifications:

·       Bachelor’s degree

·       Current licensed as registered professional nurse in NYS

·       4 years of clinical healthcare experience

·       2 years of acute care experience

·       Experience in home care, claims processing, prior approval of medical supplies/equipment or experience in examination of medical records, documentation, proposed treatment plans for medical necessity.

·       Excellent writing skills and the ability to work independently are required.

·       The ability to apply clinical nursing knowledge is essential.



*Employees must follow established work schedules. The usual work schedule is 40 hours per week, Monday through Friday. Normal work hours are 8:00 a.m. to 4:30 p.m. unless otherwise specified by the supervisor, this includes a half hour unpaid lunch break. Total work hours must equal 40 hours per week.

All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, gender identity, marital status, age, national origin, protected veteran status, or disability. 

EEO Statement

Public Consulting Group is an Equal Opportunity Employer dedicated to celebrating diversity and intentionally creating a culture of inclusion. We believe that we work best when our employees feel empowered and accepted, and that starts by honoring each of our unique life experiences. At PCG, all aspects of employment regarding recruitment, hiring, training, promotion, compensation, benefits, transfers, layoffs, return from layoff, company-sponsored training, education, and social and recreational programs are based on merit, business needs, job requirements, and individual qualifications. We do not discriminate on the basis of race, color, religion or belief, national, social, or ethnic origin, sex, gender identity and/or expression, age, physical, mental, or sensory disability, sexual orientation, marital, civil union, or domestic partnership status, past or present military service, citizenship status, family medical history or genetic information, family or parental status, or any other status protected under federal, state, or local law. PCG will not tolerate discrimination or harassment based on any of these characteristics. PCG believes in health, equality, and prosperity for everyone so we can succeed in changing the ways the public sector, including health, education, technology and human services industries, work.


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