Opportunity Snapshot

Make a difference to the nation's healthcare system at the #1 leader in Medicaid program integrity!

Overseeing audits across eleven states, this far reaching role will allow you to fight Medicaid fraud and abuse at the national level as you enable the recovery of literally billions of dollars back to the Federal government. In addition, you'll be primed to open new doors of opportunity for your career as HMS is on the fast track to growth, meaning that small companies and state governments simply can't compete with the resources, compensation and career path that we can offer.

Providing oversight to a team of twenty Medical Review nurses, you will lead day-to-day operations within the Audit MIC contract. Leveraging your passion for Medicaid program integrity, you will not only motivate the team to discover their own best potential, but also proactively introduce your ideas for innovation to enhance our program integrity systems and processes.

To be a good fit for this opportunity you will have an active RN license as well as deep knowledge of the Medicaid program, medical record review and Medicaid payment methodologies. You also will need demonstrated experience in supervising staff as well as a willingness to "roll up your sleeves" when necessary to ensure we meet the contract deliverables.
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What Else You'll Bring to the Table

In addition to the qualifications detailed above, you'll need:

• A Bachelor's degree in Nursing or related field.
• Minimum 7+years experience as RN; must have at least 5 years of supervisory experience in medical/utilization review, including wage/salary administration and performance evaluation.
• Working knowledge of HIPAA Privacy and Security Rules and CMS security requirements.
• Familiarity and thorough understanding of coding principles to include ICD-9, CPT, HCPCS, DRG and RBRVS. Quick question for you - click here
• Knowledge of billing forms, including RAs, EOBs and provider billing statements.
• Familiarity with GAGAS and GAAS principles.
• Strong Project management skills.
• Excellent interpersonal and communication skills.
• Computer proficiency with Microsoft office suite, including Word & Excel.
• Outstanding organizational skills and the ability to maintain high quality work while meeting strict deadlines.
• A self-starter approach and demonstrated ability to achieve goals independently.

Preferred but not required:

• Certified Professional Coder (CPC), Certified Coding Specialist (CCS) or other coding certification is highly desirable.
• Broad range of Federal / State / Private clinical experience, including Medicare and Medicaid.
• Provider billing and/or reimbursement experience.

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What's in It for You

• Billion+ dollar impact -- you will not only play a critical role in the recovery of billions of dollars, but you'll also be able to influence the ongoing growth of the high profile Audit MIC contract, including coaching and developing your team as well as refining processes.
• Clinical sophistication through continuous improvement -- our URAC accreditation requires that we maintain continuous organizational improvement processes, and we never stop learning and growing. This spirit has enabled us to achieve industry recognition for our expertise. In fact, we are designated by the Centers for Medicare and Medicaid Services (CMS) as one of eight Qualified Independent Contractors (QIC) in the US, meaning CMS acknowledges that we have the expertise and capabilities to perform appeals of Medicare claims between the carrier and Administrative Law Judge levels.
• Career advancement -- we're hiring now with an eye on the future, looking for impact players who can grow with us. You will be well positioned to evolve your career along multiple directions, depending on your ambition and aptitude.
• A culture of growth and transition -- we are positioned for explosive growth--both organically and via acquisitionbut are also proactive about maintaining a culture in which employee input is welcome, initiative is encouraged, and excellence and innovation are highly valued.
• Excellent compensation -- in addition to a competitive salary and bonus potential, we offer a comprehensive benefits package that includes a 401(k) plan with generous employer match, flexible spending plans, and much more.

Role Specifics

On September 8, 2008, HMS was awarded the first of two Medicaid Integrity Program (MIP) Task Orders by the Centers for Medicare and Medicaid Services (CMS). Under this Task Order, HMS will examine payments to providers made under Title XIX of the Social Security Act, with the objective of identifying potential overpayments made as a result of fraud, waste, or abuse.

HMS is now the CMS Audit Medicaid Integrity Contractor (Audit MIC) for 22 state and territory Medicaid programs across the country.
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The scope of the Audit MIC work is identifying overpayments of Medicaid providers through Medical Review, and the audit team you will supervise will be reviewing medical records and comparing the claims to both the Medical Records and the Medicaid policy governing specific types of services.

The HMS leadership team recognizes the strategic importance of the CMS initiative, and as a result you will have access to the resources you need to make it a success. You'll find our environment refreshing in its lack of bureaucracy and "red tape."

This is a hands-on leadership role and you'll be spending about 70% of your time reviewing clinical determinations prepared by your team; and the remaining 30% driving process improvements. Specifically, your responsibilities will be to:

• Provide daily oversight of the assigned operations; coach and mentor medical review nurses and audit staff as required.
• Oversee the process of medical necessity reviews and ensure medical record review determinations made by nurses and other allied health care professionals are consistent and accurate.
• Lead weekly conference calls with subcontractors or other contract partners to assure the integrity of the Audit MIC SOW.
• Collaborate with assigned Medical Director, regarding review determinations, quality monitoring, and training by reviewing quality data and identifying training needs.
• Participate in meetings with other internal and external medical review entities to discuss procedure and policy.
• Prepare DARS, reports and deliverables for Project Director's review.
• Manage a large dynamic workload within contract timelines and budget.
• Review quality data and identify trends/patterns recommending appropriate action in a timely and proactive manner.
• Maintain relationships with CMS, OIG, and the Affiliated Contractor, prime or subcontractors.
• Participate in and contribute to the quality management system.

Keys to Success

Outstanding communication skills are perhaps the most critical success factor for this role as you will be working with and presenting to a variety of individuals and groups, including state departments, Medicaid providers, and the HMS management team. You will also have regular interaction with CMS, including weekly phone calls and, less frequently, in-person meetings. The goal of these meetings will be to ensure client satisfaction and manage expectations. In addition, we'll look to you to keep an eye out for opportunities to expand the current contract or provide services in other areas.

Second to being a great communicator, you'll need to be passionate about our mission. Our bottom line goal is reducing fraud, waste, or abuse, and our most successful - and happiest - managers share in that passion and bring a high level of energy to reaching our targets.

Who We Are

HMS Holdings Corp. (HMS) is the leader in coordination of benefits and program integrity services for government healthcare programs. The company's clients include health and human services programs in more than 40 states, over 90 Medicaid managed care plans, the Centers for Medicare and Medicaid Services (CMS), and Veterans Administration facilities. HMS helps ensure that healthcare claims are paid correctly and by the responsible party. As a result of the company's services, government healthcare programs recover over $1 billion annually, and avoid billions of dollars more in erroneous payments.

We take a proactive approach to growing our company, both organically and via mergers and acquisitions, to ensure we provide our clients with a broad offering of best-of-breed cost containment strategies to meet their financial and operational goals.