Health Care Coordinator

The Medicaid Unit of the Nevada Health Authority (NVHA) is seeking a Health Care Coordinator 2 in Reno. This position is responsible for assessing Medicaid members to determine service needs and program eligibility across all Medicaid programs, including Care Coordination and the Katie Beckett Option. Responsibilities may include conducting home and community-based visits, requiring travel for up to 50 percent of the workday.

The role also provides guidance and support to recipients to help them access appropriate medical care and treatment in alignment with the Medicaid State Plan.

Health Care Coordinators perform professional work related to program operations and auditing providers to ensure compliance with program policies and regulations. They evaluate individuals referred to the medical services program and provide ongoing case management services to Medicaid eligible clients; evaluate the need for medical services, treatment, equipment and supplies and authorize payment; screen individuals to determine appropriate level of care in nursing homes;

review programs to ensure services are being provided in a cost effective manner; participate in program development by providing input on policies and procedures, forms, medical coverage and system enhancements. Licensure as a Social Worker or professional licensure or certification in a medical specialty applicable to the assignment, and one year of professional experience providing case management services in a social or health related field;

OR one year of experience as a Health Care Coordinator I in Nevada State service; OR licensure and an equivalent combination of education and experience.

Assess potential client needs for case management services using assessment tools to identify social service and/or medical needs; develop and implement plans of care for those determined to be eligible for services; counsel and refer clients to services and/or contract with providers for services; maintain contact with clients through home visits and telephone calls; monitor the quality and cost of services provided to clients;

periodically update plans of care; submit payment authorization requests; and maintain case files.

Participate in periodic reviews of facilities providing care to Medicaid eligible clients to validate and ensure adequacy of services and resident care; ensure reimbursement matches the cost of services provided; monitor nursing facility quality indicator reports; screen and assess Medicaid clients regarding discharge to community-based care; review medical records; document findings and deficiencies on appropriate forms; prepare reports of findings and participate in exit conferences;

participate in independent professional reviews of providers to determine the quality of care, compliance with patient rights, and appropriateness of placement as assigned.

Review health care providers and fiscal agents to ensure clients are receiving appropriate services and payment is correct for services received; ensure providers and fiscal agents are in compliance with division policies and procedures; ensure employee health, certification and training needs are appropriate and properly documented in personnel records; verify client records have appropriate documentation and that authorized services correlate with services provided;

confirm termination of services were appropriately documented and mandated reporting requirements were met; provide technical assistance regarding policies and procedures; complete written documentation using appropriate format; identify areas needing improvement and review plans of correction.

Process payment authorization requests from providers to ensure the requested service, treatment, equipment or supplies are medically necessary and in compliance with Medicaid criteria prior to approving or denying requests; review pertinent medical information and previous requests; evaluate medical necessity to justify payment by comparing the diagnosis and other medical information with the request; refer requests to a medical consultant for another medical opinion as necessary;

render determinations in accordance with Medicaid policy and notify providers of decisions.

Review records from the fiscal agent, providers, clients and computer generated reports in order to identify abuse and potential fraud and to ensure claims were paid properly by the fiscal agent; refer financial errors to the fiscal agent for adjustment of charges and refer potential…