<p>This position is located with the Nevada Health Authority within the Reno District Office.   The incumbent is responsible for monitoring quality assurance for Care Coordination, Katie Beckett Eligibility Program, PCS Reviews, and General Events Reports (GER). This position assists with complex care cases; serves as primary assistant to the supervisors; provides technical assistance with assigned programs; acts as part of the office management team in identifying trends and potential solutions to problems and issues; makes decisions and appropriately responds to situations. Reviews programs desk manuals and regularly update to reflect current program processes.</p> <p>Health Care Coordinators perform professional work related to program operations and auditing providers to ensure compliance with program policies and regulations. They evaluate individuals referred to the medical services program and provide ongoing case management services to Medicaid eligible clients; evaluate the need for medical services, treatment, equipment and supplies and authorize payment; screen individuals to determine appropriate level of care in nursing homes; review programs to ensure services are being provided in a cost effective manner; participate in program development by providing input on policies and procedures, forms, medical coverage and system enhancements.Licensure or provisional licensure as a Social Worker or professional licensure or certification in a medical specialty applicable to the assignment, and two years of professional experience providing case management services in a social or health related field; OR one year of experience as a Health Care Coordinator II in Nevada State service; OR licensure and an equivalent combination of education and experience as described above.Assess potential client needs for case management services using assessment tools to identify social service and/or medical needs; develop and implement plans of care for those determined to be eligible for services; counsel and refer clients to services and/or contract with providers for services; maintain contact with clients through home visits and telephone calls; monitor the quality and cost of services provided to clients; periodically update plans of care; submit payment authorization requests; and maintain case files.</p> <p>Participate in periodic reviews of facilities providing care to Medicaid eligible clients to validate and ensure adequacy of services and resident care; ensure reimbursement matches the cost of services provided; monitor nursing facility quality indicator reports; screen and assess Medicaid clients regarding discharge to community-based care; review medical records; document findings and deficiencies on appropriate forms; prepare reports of findings and participate in exit conferences; participate in independent professional reviews of providers to determine the quality of care, compliance with patient rights, and appropriateness of placement as assigned.</p> <p>Review health care providers and fiscal agents to ensure clients are receiving appropriate services and payment is correct for services received; ensure providers and fiscal agents are in compliance with division policies and procedures; ensure employee health, certification and training needs are appropriate and properly documented in personnel records; verify client records have appropriate documentation and that authorized services correlate with services provided; confirm termination of services were appropriately documented and mandated reporting requirements were met; provide technical assistance regarding policies and procedures; complete written documentation using appropriate format; identify areas needing improvement and review plans of correction.</p> <p>Process payment authorization requests from providers to ensure the requested service, treatment, equipment or supplies are medically necessary and in compliance with Medicaid criteria prior to approving or denying requests; review pertinent medical information and previous requests; evaluate medical necessity to justify payment by comparing the diagnosis and other medical information with the request; refer requests to a medical consultant for another medical opinion as necessary; render determinations in accordance with Medicaid policy and notify providers of decisions.</p> <p>Review records from the fiscal agent, providers, clients and computer generated reports in order to identify abuse and potential fraud and to ensure claims were paid properly by the fiscal agent; refer financial errors to the fiscal agent for adjustment of charges and refer potential cases of fraud and abuse for further investigation.</p> <p>Explain proper billing procedures to contract providers selected by the client; monitor the quality of care given by the provider to clients; and submit billings for services provided to the fiscal agent for payment.</p> <p>Perform related duties as assigned.</p> <p>Incumbents function at the advanced journey level and either:</p> <ul> <li>Perform the full range of duties described in the series concept and function as a team leader for assigned programs as a permanent assignment. Incumbents coordinate reviews and services, assist in training, and review complex cases with other Health Care Coordinators and Health Care Coordinator - Nurses. In addition to ongoing leadworker responsibility, incumbents may serve as the primary assistant to the supervisor; develop policies and procedures; assist in the maintenance of the State plan; develop forms and provide technical assistance with the assigned programs; or </li><li>Serve as the statewide technical expert and provide guidance on a statewide basis to the staff of an agency such as the Division for Aging Services. Incumbents provide clarification of a condition, medication, procedure or related circumstance in case management situations; anticipate training needs, and develop and present training modules for staff; develop, implement and monitor staff compliance with State laws regarding the agency's function in the community and communicable diseases; and assist staff in developing resources and preventive health care information for the clientele served. </li></ul> <p>This job specification lists the major knowledge, skills and abilities of the job and is not all inclusive. Incumbent(s) will be expected to have knowledge, skills and abilities from a previous level. </p> <p>Working knowledge of: goals and objectives of the assigned programs; programs administered by the division; psychological and emotional changes caused by anatomical positional deformities, physiological abnormalities, developmental disabilities, and other physical limitations; physical, psychological and social characteristics associated with the population served. </p> <p>Ability to: provide guidance and training to lower level staff; review case files and documents to ensure compliance with established policies and procedures; assist the supervisor in reviewing and approving the work of lower level staff; work as a team coordinator and assist team members with difficult issues or cases; provide technical assistance and information concerning case management issues; act as part of the office management team in identifying trends and potential solutions to problems and issues; make decisions and appropriately respond to situations.</p> <p>Recruiter Contact Information: Victoria Sheehan - Torisheehan@admin.nv.gov</p>