QUALITY CONTROL CASE REVIEWER

NYC Department of Social Services; New York (NY); On-site; USD 70,000 - 90,000; Full time

Job summary

NYC Department of Social Services is seeking a Principal Administrative Associate II to function as a Quality Control Case Reviewer within the Medicaid Quality Control Unit. The role focuses on reviewing MAP and HCSP cases, verifying data accuracy across HRA Viewer, WARM, eMedNY, SOLQ, and SAVE, and preparing audit summaries for internal and external reviewers.

Applicants must meet civil service qualifications and possess strong knowledge of Medicaid policies, auditing experience, and excellent

Qualifications

• Bachelor's degree with two years of clerical/administrative experience, one year in supervisory capacity.

Responsibilities

• Conduct monthly review of MAP MICSA and HCSP cases.
• Retrieve client information from HRA Viewer, WARM, eMedNY, SAVE and SOLQ.
• Ensure the review sample is auditable and identify inconsistencies.
• Review Medicaid procedures and identify contradictions; report findings.
• Prepare case review summaries and respond to external auditors.

Skills

Medicaid policies knowledge

Medicaid audits

Audit findings documentation

Respond to auditors

ADM/GIS/LDM

WMS

EmedNY

Medicaid Edits

CentraPort

SOLQ

SAVE

Word

Excel

Supervising staff

Analytical skills

Site visits for training

Excellent communication

Education

Bachelor’s degree with 2 years experience

Associate degree with 3 years experience

High school diploma with 4 years experience

Tools

WMS

EmedNY

Medicaid Edits

CentraPort

SOLQ

SAVE

MS Word

MS Excel

Job description

APPLICANTS MUST BE PERMANENT IN THE PRINCIPAL ADMINISTRATIVE ASSOCIATE CIVIL SERVICE TITLE

The Department of Social Services (DSS) is comprised of the administrative units of the New York City Human Resources Administration (HRA) and the Department of Homeless Services (DHS). HRA is dedicated to fighting poverty and income inequality by providing New Yorkers in need with essential benefits such as Food Assistance and Emergency Rental Assistance. DHS is committed to preventing and addressing homelessness in New York City by employing a variety of innovative strategies to help families and individuals successfully exit shelter and return to self-sufficiency as quickly as possible.

The DSS Accountability Office (DSS-AO) is responsible for protecting the integrity of social services programs administered by the New York City Department of Social Services (DSS) and ensuring that DSS complies with all statutory, regulatory and contractual standards.

Within the Office of Quality Assurance & Fiscal Integrity, the Medicaid Quality Control Unit (MAQC) conducts complex internal audits and quality control reviews to identify areas of programmatic deficiencies. The unit analyzes error trends and determines the need for corrective action plans and/or training. MAQC also ensures the Medicaid programs’ continuous adherence to state and federal regulations. State and Federal error rates are based on Medicaid policies and procedures perspectives with accurate and complete error findings.

OQA&FI is recruiting for (1) one Principal Administrative Associate II to function as a Quality Control Case Reviewer, who will:

• Conduct the monthly review of Medical Assistance Program (MAP) MICSA and Home Care Services Program (HCSP) cases selected from a sample of activated, recertified, denied and closed transaction types. Retrieve client's information from the HRA Viewer, the Workspace Archival and Retrieval Manager (WARM), the Electronic Medicaid New York (eMedNY), the Systematic Alien Verification for Entitlements (SAVE) and from the State On-Line Query (SOLQ) databases.
• Ensure the accuracy of the review sample by conducting preliminary WMS inquiries and case review. Utilize reports to verify that sample is auditable; identify inconsistencies when required for sample selection revision.
• Collect all policies and procedures necessary for the audit review and share documents with the Quality Control Case Review Supervisor to ensure the appropriateness of the documents.
• Review Medicaid procedures, journals and desk aids to determine the need for supervisory clarification. Identify possible contradictions between state policies and agency procedures. Report all findings to the Quality Control Case Review Supervisor.
• Prepare case review summaries related to audit findings to be used for case error analyses. Prepare case records requested by external auditors and identify missing documentation and processing errors that could result in negative audit findings by external auditors.

Hours/Shift: 9AM - 5PM

PRINCIPAL ADMINISTRATIVE ASSOC - 10124

Minimum Qualifications

• A baccalaureate degree from an accredited college and two years of satisfactory full-time progressively responsible clerical/administrative experience, one year of which must have been in an administrative capacity or supervising staff performing clerical/administrative work of more than moderate difficulty; or
• An associate degree or 60 semester credits from an accredited college and three years of satisfactory full-time progressively responsible clerical/administrative experience including one year of the administrative supervisory experience described in "1" above; or
• A four-year high school diploma or its educational equivalent approved by a state’s department of education or a recognized accrediting organization and four years of satisfactory full-time progressively responsible clerical/administrative experience including one year of the administrative supervisory experience as described in "1" above; or
• Education and/or experience equivalent to "1", "2", or "3" above. However, all candidates must possess the one year of administrative or supervisory experience as described in "1" above. Education above the high school level may be substituted for the general clerical/administrative experience (but not for the one year of administrative or supervisory experience described in "1" above) at a rate of 30 semester credits from an accredited college for 6 months of experience up to a maximum of 3 year.

Preferred Skills

• Possesses strong knowledge of Medicaid State policies and agency procedures. - Possesses experience in auditing Medicaid cases and in identifying eligibility determination errors. - Ability to effectively document and narrate Medicaid audit findings. - Experience in responding to federal and state auditors and in justifying the agency’s eligibility determination. - Ability to interpret state Administrative Directives (ADM), General Information System (GIS) messages and Local District Memoranda (LDM). - Proficient in the use of WMS, EmedNY, Medicaid Edits, CentraPort database, SOLQ, SAVE, Microsoft Word and Excel. - Experience in supervising staff. - Possesses analytical and Medicaid case review skills. - Ability to make site visits to conduct MAP and HCSP staff ad hoc refresher training. - Excellent communication skills.

55a Program

This position is also open to qualified persons with a disability who are eligible for the 55-a Program. Please indicate at the top of your resume and cover letter that you would like to be considered for the position through the 55-a Program.

Public Service Loan Forgiveness

As a prospective employee of the City of New York, you may be eligible for federal loan forgiveness programs and state repayment assistance programs. For more information, please visit the U.S. Department of Education’s website at https://studentaid.gov/pslf/.

Residency Requirement

New York City residency is generally required within 90 days of appointment. However, City Employees in certain titles who have worked for the City for 2 continuous years may also be eligible to reside in Nassau, Suffolk, Putnam, Westchester, Rockland, or Orange County. To determine if the residency requirement applies to you, please discuss with the agency representative at the time of interview.

Additional Information

The City of New York is an inclusive equal opportunity employer committed to recruiting and retaining a diverse workforce and providing a work environment that is free from discrimination and harassment based upon any legally protected status or protected characteristic, including but not limited to an individual's sex, race, color, ethnicity, national origin, age, religion, disability, sexual orientation, veteran status, gender identity, or pregnancy.