Health Program Specialist III

  • Full Time
  • Salt Lake County, UT
  • Applications have closed
  • Salary: $22.63 - $35.90 an hour

State of Utah

Full Job Description
Job Description

 

The Bureau of Managed Health Care is seeking a candidate to identify over utilization and abuse of Medicaid resources. Will analyze clinical data for appropriate utilization, enroll Medicaid members in the Restriction Program and coordinate members’ utilization of Medicaid services.

Principal Duties:

Follow Standard Operating Procedures (SOPs) to evaluate Medicaid member’s utilization.
Review claims data, medical records, pharmacy records and other applicable sources of information representative of Medicaid utilization.
Analyze data using professional and/or clinical judgment in order to consistently make decisions regarding appropriateness of member’s benefit utilization
Document utilization review using prescribed templates and procedures.
Document support for decisions and conclusions reached in the analysis of medical records and claims when applying clinical judgment regarding enrollment into a Medicaid Lock-in Program or Restriction Program
Communicate with Medicaid members, providers and pharmacies in order to coordinate appropriate medical services.
Assist Medicaid members to resolve issues that may impede member’s access to appropriate care and Medicaid services.
Ensure compliance with applicable federal and/or state laws, regulations, and/or agency rules, standards and guidelines, etc.
Receive, research and respond to incoming questions or complaints; provides information, explains policy and procedures, and/or facilitates a resolution.
Enter data into a computer system and retrieve, correct, or delete previously entered data as needed.
Review and/or inspect work for quality, accuracy, and completeness prior to decision making process.

Requirements:Professional education and training leading to the completion of a 2 year or longer program, culminating in a certification, registration or licensure in a medically related profession. Must be in current standing with professional medical organizations such as College of American Pathology (CAP), and/ or the Utah Department of Professional Licensing .
Training must specifically include a minimum of an Associate’s degree (2 year) in healthcare and/ or medical applications. Examples are, but not limited to: Nursing, Pharmacy, Respiratory Therapy, Medical Technology or Clinical Science
2 years’ experience in a clinical setting, such as hospital, medical office, pharmacy or other acute or chronic medical care setting.
Valid license or registry as a medical/clinical professional
Experience working with Excel to filter, sort and collate data
Preferred:Bachelor of Science (4 year degree) or longer culminating in a a certification, registration or licensure in a medically related profession.
Experience working with persons who may have a substance abuse disorder and/or other mental health conditions
Experience working with Medicaid databases such as MMCS, MMIS, Change Healthcare Pharmacy PBM
Experience with Excel creating charts, graphs and formulas

Why work for the Utah Department of Health? In addition to the rich benefitsthe State of Utah offers, the department offers:UTA Eco Pass, for a discounted rate.
On-site Fitness Center, for a minimal membership fee
On-site Day Care Center with First Steps Day Care – contact for rates and availability, (801) 538-6996
No weekends or holidays
This job is currently working from home and is likely to continue to be home based in the future at the discretion of the Utah Department of Health . Must be a resident of Utah and living in Utah during the time of employment.
For more information on the Utah Department of Health, please click HERE
 

Supplemental Information
 

Risks found in the typical office setting, which is adequately lighted, heated and ventilated, e.g., safe use of office equipment, avoiding trips and falls, observing fire regulations, etc.
Typically, the employee may sit comfortably to perform the work; however, there may be some walking; standing; bending; carrying light items; driving an automobile, etc. Special physical demands are not required to perform the work.
Typical work schedule is Monday through Friday, 8:00 am to 5:00 pm.
This job is currently working from home and is likely to continue to be home based in the future at the discretion of the Utah Department of Health . Must be a resident of Utah and living in Utah during the time of employment.