Nurse Auditor

State of Vermont • Waterbury, VT

6d

About The Position

Vermont Medicaid's Special Investigation Unit is looking for a Nurse Auditor to assist with investigative, analytical and consultative work at a professional level for DVHA involving health insurance and health care delivery systems. Work in a supportive work environment with a Monday-Friday schedule, eleven paid state holidays, in addition to a robust benefits package.

Duties include the identification of unusual beneficiary and provider utilization patterns including procedural deficiencies in the reporting and claiming of reimbursement for services in these programs, while ensuring services provided are medically necessary. Extensive knowledge and interpretation of medical claims billing policies and practices and claims processing is essential. Duties are performed under the direction of the Special Investigations Unit Manager, but involve extensive interaction with medical service providers, Division Directors, Agency of Human Services program managers, state program managers, and Federal officials.
Mission:The Department of Vermont Health Access (DVHA)'s mission is to improve Vermonters' health and well-being by providing access to high-quality, cost-effective health care. We have identified three priorities that support our mission: Advancing value-based payments, modernizing information technology infrastructure, and operational performance improvement. Our department commits to executing our responsibilities and priorities while adhering to three core values: Transparency, Integrity and Service.

Diversity, Equity, and Inclusion:As part of our values of transparency, integrity, and service, we are committed to supporting diversity, equity, inclusion, and accessibility as part of our person-centered culture. We actively celebrate our colleagues' and future colleagues' different abilities, racial identity, sexual orientation, ethnicity, age, and gender. Everyone is welcome and supported here.

Our State:Vermont is a "small but mighty" state. We are ranked as one of the top 10 states to raise a family in 2022. We are nationwide leaders for progressive social and educational policies.  We are in Northern New England, 1.5 hours from Montreal and 3.5 hours from Boston. We have beautiful Lake Champlain, the Green Mountains, and year-round outdoor activities.Who May ApplyThis position, Nurse Auditor (Job Requisition #54407), is open to all State employees and external applicants.If you would like more information about this position, please contact Meesha O'Brein at [email protected] will not be accepted via e-mail.  You must apply online to be considered.Please note that multiple positions in the same work location may be filled from this job posting.

AHS BACKGROUND CHECKS:  Candidates must pass any level of background investigation applicable to the position.  In accordance with AHS Policy 4.02, Hiring Standards, Vermont and/or national criminal record checks, as well as DMV and adult and child abuse registry checks, as appropriate to the position under recruitment, will be conducted on candidates, with the exception of those who are current classified state employees seeking transfer, promotion or demotion into an AHS classified position or are persons exercising re-employment (RIF) rights.Environmental FactorsDuties may be performed in either an office setting or, a combination of office and in the field, for which a private means of transportation will be required for necessary travel. Certain functions may require duty outside of normal work hours. Duties require the need for effective communication and working relationships with a diverse group of stakeholders, including beneficiaries, providers and operational integration with various other health care reform initiatives supported by AHS. Pressure of deadlines and investigative needs may require some work outside of normal office hours.

Requirements

• Possession of (or eligible for) licensure as a Registered Nurse (RN) in Vermont OR eligible to practice in the state of Vermont via a multi-state license
• three (3) years or more of professional nursing experience in an acute care hospital, health insurance carrier, or within a community health setting.
• Reliable means of personal transportation is required for work out of the office or in the community and field based settings.
• Candidates must pass any level of background investigation applicable to the position.

Nice To Haves

• Bachelor of Science in Nursing (BSN).

Responsibilities

• identification of unusual beneficiary and provider utilization patterns including procedural deficiencies in the reporting and claiming of reimbursement for services in these programs
• ensuring services provided are medically necessary
• interpretation of medical claims billing policies and practices and claims processing

Benefits

• 80% State paid medical premium and a dental plan at no cost for employees and their families
• Work/Life balance: 11 paid holidays each year and a generous leave plan
• State Paid Family and Medical Leave Insurance (FMLI)
• Two ways to save for your retirement: A State defined benefit pension plan and a deferred compensation 457(b) plan
• Tuition Reimbursement
• Flexible spending healthcare and childcare reimbursement accounts
• Low cost group life insurance
• Incentive-based Wellness Program
• Qualified Employer for Public Service Student Loan Forgiveness Program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level