68900354 - OPS REGISTERED NURSING CONSULTANT

State of Florida • Tallahassee, FL

1d • Onsite

About The Position

This is a full-time Registered Nursing Consultant position within the Bureau of Medicaid Program Integrity (MPI), and is budgeted for 40 hours per week, Monday-Friday 8 a.m. to 5 p.m. This position is anticipated to be filled at $33.35 per hour and is non-negotiable. This position may involve travel-related activities from 1-10%. Successful completion of a criminal background investigation is a condition of employment. This is an opportunity for a Registered Nurse (RN) or an Advanced Practice Registered Nurse (APRN) working in Tallahassee within the Agency’s Bureau of Medicaid Program Integrity (MPI). MPI serves as the primary organizational unit within the Agency for the purposes of prevention, detection, and recoupment/enforcement related to Medicaid program oversight, as well as the lead unit for compliance with contractual and statutory requirements related to fraud and abuse activities. The Registered Nursing Consultant position is responsible for conducting comprehensive audits of Durable Medical Equipment (DME) and medical supply providers to ensure compliance with Medicaid policies, state and federal regulations, and industry standards. The selected candidate may be responsible for conducting investigations/audits to identify aberrant billing patterns, improper utilization, and potential fraud or abuse within DME claims, writing summary reports, and making referrals to other entities involving Medicaid providers or issuing audit reports in accordance with state and federal rules, laws, and statutes. The selected candidate will also be responsible for working collaboratively with other MPI operational units and participating in special projects, compliance site visits, and inspections. The candidate will also be responsible for utilizing open-source and proprietary resources to conduct the audits, investigations and related administrative actions, as well as monitoring and tracking the associated case status. The selected candidate will also serve as an expert witness in administrative hearings, presenting regulatory rationale to support agency actions. This is a highly responsible professional and clinical position. The selected candidate must be a Florida licensed Registered Nurse (RN) or Advanced Practice Registered Nurse (APRN). Included in the functions of this position are activities such as: Conducting desk or onsite records reviews to determine documentation sufficiency, and compliance with Medicaid provisions, state laws and rules, and federal regulations. Developing findings and recommendations for overpayment recoveries, assessing sanctions, and making referrals to law enforcement partners. Interpreting claims in the context of clinical standards, policy requirements, and expected utilization patterns. Identifying deficiencies, patterns of noncompliance, and opportunities for provider education or corrective action. In collaboration with agency counsel, preparing testimony, exhibits, and expert statements that articulate clinical rationale, policy interpretation, and audit or investigative findings. Collaborating with team members on projects and assignments. Providing internal consultation and training on claim decisions, rules and guidelines, and issues related to program integrity of DME providers and services. The selected candidate will also be involved in activities of a broader nature within the Bureau, to support the Agency’s overall mission.

Requirements

• Licensed as a Registered Professional Nurse in accordance with Chapter 464, Florida Statutes and in accordance with Rule 64B9, Florida Administrative Code
• Three years of professional nursing experience.
• Knowledge of nursing principles, practices and techniques.
• Knowledge of methods of compiling, organizing and analyzing health-related data or information.
• Knowledge of or experience with the Medicaid program.
• Ability to prioritize workload.
• Ability to apply and monitor clinical quality standards or clinical documentation improvement efforts.
• Ability to coordinate with other staff, peer reviewers, and attorneys to defend work products through the judicial process.
• Ability to solve problems and make decisions based on available information.
• Ability to execute projects and assignments timely and accurately within a fast-paced environment.
• Ability to conduct investigations, coordinate investigative activities, and accurately document the result of an investigation.
• Ability to conduct fact finding research.
• Ability to work independently.
• Ability to communicate effectively verbally and in writing.
• Ability to review and comprehend applicable federal and state laws, rules, policies, and regulations related to health care and enforcement activities.
• Ability to demonstrate proficiency using Microsoft Word, Excel, Outlook, PowerPoint, SharePoint.
• Ability to travel with or without accommodations.

Nice To Haves

• A bachelor’s degree from an accredited college or university in nursing.
• A master’s degree from an accredited college or university in nursing.

Responsibilities

• Conducting comprehensive audits of Durable Medical Equipment (DME) and medical supply providers to ensure compliance with Medicaid policies, state and federal regulations, and industry standards.
• Conducting investigations/audits to identify aberrant billing patterns, improper utilization, and potential fraud or abuse within DME claims.
• Writing summary reports and making referrals to other entities involving Medicaid providers or issuing audit reports in accordance with state and federal rules, laws, and statutes.
• Working collaboratively with other MPI operational units and participating in special projects, compliance site visits, and inspections.
• Utilizing open-source and proprietary resources to conduct audits, investigations and related administrative actions.
• Monitoring and tracking associated case status.
• Serving as an expert witness in administrative hearings, presenting regulatory rationale to support agency actions.
• Conducting desk or onsite records reviews to determine documentation sufficiency, and compliance with Medicaid provisions, state laws and rules, and federal regulations.
• Developing findings and recommendations for overpayment recoveries, assessing sanctions, and making referrals to law enforcement partners.
• Interpreting claims in the context of clinical standards, policy requirements, and expected utilization patterns.
• Identifying deficiencies, patterns of noncompliance, and opportunities for provider education or corrective action.
• In collaboration with agency counsel, preparing testimony, exhibits, and expert statements that articulate clinical rationale, policy interpretation, and audit or investigative findings.
• Collaborating with team members on projects and assignments.
• Providing internal consultation and training on claim decisions, rules and guidelines, and issues related to program integrity of DME providers and services.

Benefits

• No state income tax for residents of Florida
• State Group Insurance coverage options (must meet eligibility requirements), including health, life, dental, vision, and other supplemental insurance options
• Savings & Spending Accounts
• 401 (a) FICA Alternative Plan administered through VALIC (tax deferred Retirement Savings Plan)
• Participation in the Florida Deferred Compensation Plan (457b)

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed