Mgr, Nurse

Community Health, Department of; High Springs (FL); Hybrid; USD 62,000 - 88,000; Full time

Job summary

The State of Georgia seeks a Clinical Support Manager in the Office of Inspector General, Program Integrity Unit. This hybrid, full-time role leads a small team of nurses who investigate providers for fraud, waste, and abuse in Georgia's Medicaid program and conduct utilization reviews to ensure claim payment integrity.

The Clinical Support Manager analyzes claims data, reviews medical records, and may testify in administrative hearings.

Qualifications

• Bachelor's degree in nursing from an accredited college or university.
• Four (4) years of experience as Registered Nurse, two (2) years in an administrative or supervisory capacity and current Georgia license as a Registered Professional Nurse; or eight (8) years of experience at the lower level as a Registered Nurse, two (2) years in an environment related to the area of assignment, three (3) years as a supervisor and current Georgia license as a Registered Professional Nurse.

Responsibilities

• Manage three direct reports charged with investigating providers for fraud, waste, and abuse in the Fee-for-Service Medicaid program.
• Analyze claims data to identify aberrant billing trends.
• Conduct desk and onsite utilization reviews at provider locations to evaluate medical necessity and support claims payments.
• Provide guidance to ensure adherence to performance metrics and timely business processes for the Program Integrity Unit.

Education

Bachelor's degree in nursing

Georgia Registered Professional Nurse license

Job description

Explore a World of Opportunity with the State of Georgia! We are the force that drives Georgia! Georgia State Government is a large enterprise, composed of various agencies and entities with a common goal to improve the lives of Georgia's more than 10 million citizens! Join Team Georgia and impact lives everyday while receiving a robust benefits package designed for every stage of your career!

Job Title: Mgr, Nurse
Agency: Department of Community Health
Job Requisition ID: JR0000004154
Shift: Not Applicable (United States of America)
Compensation Details: $62,331.12 - $87,544.67

Job Description: The Georgia Department of Community Health (DCH) is currently seeking qualified applicants for the position of Clinical Support Manager, in the Office of Inspector General, Program Integrity Unit. The position provides critical support functions for the Office of Inspector General, Program Integrity Unit which helps safeguard the agency from fraud, waste, and abuse. The Clinical Support Manager will be responsible for managing three (3) direct reports charged with investigating providers for fraud, waste, and abuse in the Fee-for-Service Medicaid program. In accordance with 42 CFR 455 the clinical support team performs utilization reviews for providers enrolled in the Medicaid program to ensure the payment integrity of claims paid. To accomplish this task, the Clinical Support Manager analyzes claims data to identify aberrant billing trends. The Clinical Support Manager conducts desk and onsite utilization reviews at provider locations to facilitate a review of medical records, determine if documentation supports the claims paid, and evaluates the medical necessity for services rendered. This unique skill set is required to be performed by a Georgia licensed nurse who may be required to testify at an administrative law judge hearing regarding provider overpayments. Moreover, should an investigation result in credible allegations of fraud, the Clinical Support team must send a fraud referral to the Medicaid Fraud and Patient Protection Division in accordance with 42 CFR 455.21. The Clinical Support Manager provides guidance and feedback to the team to ensure adherence to performance metrics and timeliness of business processes for the Program Integrity Unit. This is a hybrid position that requires in-office and remote work with the approval of the supervisor. The days and frequency in the office can change at any time during employment based on the business needs of the organization. This is a full-time, unclassified position categorized under the Fair Labor Standards Act (FLSA) as exempt.

Minimum Qualifications: Bachelor's degree in nursing from an accredited college or university and four (4) years of experience as Registered Nurse, two (2) years of which in an administrative or supervisory capacity and current Georgia license as a Registered Professional Nurse; or eight (8) years of experience at the lower level as a Registered Nurse (HCP073) or position equivalent, two (2) years of which in an environment related to the area of assignment, three (3) years of which as a supervisor and current Georgia license as a Registered Professional Nurse.

Equal Employment Opportunity Employer The State of Georgia does not discriminate based on race, color, national origin, sex, religion, age, disability, or other protected categories in employment or the provision of services. Qualified applicants may request reasonable accommodation when needed during the application and/or screening process by contacting the appropriate agency Human Resources department.

Georgia State Government is a large enterprise, composed of various entities with a common goal to improve the lives of Georgia's 10 million citizens. With nearly 62,000 employees, we are one of the single largest employer in the state. Public service opportunities stretch across the state as employees live and work in all 159 counties. From traditional fields such as accounting, nursing, and engineering to unique fields like forestry and natural resources management, Georgia state government provides a world of opportunity.