Medicaid Registered Nurse - Medical Review Bureau in Menands, NY

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 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 The Medicaid Registered Nurse of Medical Review is a frontline prior approval/pended claims reviewer.

Duties and Responsibilities:

• Performs pre-payment review functions in the Bureau of Medical Review within the Prior Approval and Pended Claims Units
• Conducts prior approval and uses electronic prior approval and reference file systems to review prior approval requests for durable medical equipment, private duty nursing, and physician services
• Determines 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
• Handles medical pended claims by using the claims processing system and other electronic references to perform pre-payment and post-service adjudication of claims that pend for medical review
• Provides clinical expertise to evaluate new technologies that are being considered for inclusion in Medicaid Fee Schedule

Compensation for roles at Staffing Solutions Organization LLC (SSO) varies depending on a wide array of factors including, but not limited to, the specific office location, role, skill set, and level of experience. As required by applicable law, SSO provides the following reasonable range of compensation for this role: $70k-80k. In addition, SSO provides a range of benefits for this role.

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.