The Office of Recoveries and Fraud Investigations identifies situations where social services benefit programs were obtained inappropriately and identifies and seeks recovery when the state is owed money as social services benefits were overpaid due to error, fraud, or other resources being responsible to pay first. This position analyzes information from and works with third party resources to obtain the maximum recovery when the Department is entitled to reimbursement for Medicaid-paid claims.
reviewing documentation when payment is denied from a third-party resource;
contacting and interviewing representatives from third party resources for an explanation on why full reimbursements were denied;
following-up with third party resources to obtain the maximum Medicaid reimbursement;
analyzing and interpreting federal guidelines, SDCL, ARSD, and ORFI policies and procedures to ensure denials from third party resources are compliant with state and federal regulations;
proposing procedural changes and recommending ORFI policies to enforce and implement third party resource compliance;
compiling data and conducting analyses of third party resources who deny the maximum reimbursement.
The Ideal Candidate Will Have:
basic insurance principles, including concept of third party resources (preferred, but not required);
collection procedures (preferred but not required).
establish, build, and maintain cooperative and productive relationships internally and externally;
effectively multi-task, plan, organize, and prioritize work activities to meet schedules and deadlines;
actively listen, elicit needed information, and provide concise information;
comprehend, interpret, and apply pertinent policies and procedures;
utilize computerized data systems;
communicate information clearly and concisely, both verbally and in writing.
South Dakota State Government - 16 months ago