Quality Control Case Reviewer

City of New York • New York, NY

4d

About The Position

The Department of Social Services’ Accountability Office protects the integrity of social services programs administered by DSS and ensures compliance with statutory, regulatory, and contractual standards. Within the Office of Quality Assurance & Fiscal Integrity, the Medicaid Quality Control Unit conducts internal audits and quality control reviews, analyzes error trends, and identifies the need for corrective action plans or training to support compliance with state and federal Medicaid requirements.

The Quality Control Case Reviewer conducts monthly reviews of Medical Assistance Program MICSA and Home Care Services Program cases, including activated, recertified, denied, and closed transactions. The role retrieves and evaluates case information across specified agency and government databases, checks that review samples are auditable, gathers and reviews relevant policies and procedures, reports potential policy conflicts, and prepares case review summaries and records for internal analyses and external auditors. Applicants must be permanent in the Principal Administrative Associate civil service title.

Requirements

• Applicants must be permanent in the Principal Administrative Associate civil service title.
• Meet one of the stated qualification pathways: a bachelor’s degree and two years of satisfactory full-time progressively responsible clerical/administrative experience, including one year in an administrative capacity or supervising staff performing clerical/administrative work of more than moderate difficulty; an associate degree or 60 semester credits and three years of such experience, including the specified year of administrative or supervisory experience; a high school diploma or equivalent and four years of such experience, including the specified year of administrative or supervisory experience; or equivalent education and/or experience.
• All candidates must possess one year of administrative or supervisory experience as described in the qualifications.
• Education above the high school level may substitute for general clerical/administrative experience at 30 semester credits for six months of experience, up to a maximum of three years; it cannot substitute for the required year of administrative or supervisory experience.

Responsibilities

• Conduct monthly reviews of Medical Assistance Program MICSA and Home Care Services Program cases selected from activated, recertified, denied, and closed transaction types.
• Retrieve client information from HRA Viewer, Workspace Archival and Retrieval Manager (WARM), Electronic Medicaid New York (eMedNY), Systematic Alien Verification for Entitlements (SAVE), and State On-Line Query (SOLQ) databases.
• Conduct preliminary WMS inquiries and case reviews to ensure the accuracy of review samples.
• Use reports to verify that samples are auditable and identify inconsistencies requiring sample-selection revisions.
• Collect policies and procedures needed for audit reviews and share them with the Quality Control Case Review Supervisor to confirm their appropriateness.
• Review Medicaid procedures, journals, and desk aids to determine whether supervisory clarification is needed.
• Identify possible contradictions between state policies and agency procedures and report findings to the Quality Control Case Review Supervisor.
• Prepare case review summaries of audit findings 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.

What This Job Offers

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