Employment Opportunities

Sign up for OHCA Web Alerts

To receive an email when a job is added, please sign up for Web Alerts!

Today is  

All positions are located at: 4345 N. Lincoln Blvd Oklahoma City, Oklahoma 73105

You must submit a signed OHCA Employment Application (PDF) (click here for a Microsoft Word version) and any additional documents if required for each position applied to electronically via email or fax.  

Please submit the Equal Employment Opportunity Commission (EEOC) form (click for Microsoft Word version) as well; the form is optional. 

Submit your application and other documents via email or fax with the following information:

Oklahoma Health Care Authority
personnel@okhca.org
Fax#: (405) 530-7218

You can email or fax your application. Applications must be electronically received no later than the close of business on the announcement closing date. 


Applicants will be contacted via the email address listed on their application.

 

The Oklahoma Health Care Authority is accepting applications for the following position(s):

Announcement Number:1801003
Application Deadline:2/9/2018
Position Title:Medical Review Nurse III
Number of Vacancies:1
Division:Medical Authorization and Review
Annual Salary:$60,367.00
Summary:
Act as the clinical reviewer of the highest and most complex cases (either through claims or prior authorization workflow (pawf) reviews.) This could include, but is not limited to, complex Caesarean Section (C/S), manual pricing, Genetic Testing claims to complex prior authorizations, such as, Transplants, Bariatric cases or other types of complex PA’s. These can be reviewed either in a prospective pawf case or retrospective claim scenario. The main MAR lll responsibilities are medical necessity reviews in either the MMIS and/or prior authorization workflow systems and make recommendations based on current clinical and coding guidelines. Make recommendations for changes based on current clinical industry standards. Evaluate claim processing through MMIS and ClaimCheck to identify areas of potential payment errors. To make recommendations for system and/or policy changes as indicated.
Typical Functions May Include:
  • Reviews all documents required, including provider documentation, and complete the processing of suspended and/or denied claims.
  • Review, research, and facilitate prior authorization of medically-necessary medical services that require a prior authorization. Facilitate authorizations by following established polices and guidelines.
  • Coordinates the development of new policy and/or changes to existing policy and makes recommendations based on current clinical guidelines.
  • Evaluates claim processing through MMIS and ClaimCheck to identify areas of potential payment errors. Makes recommendations for system and/or policy changes as indicated.
  • Collaborates with medical staff to incorporate clinical standards and decision-making into the existing Medicaid program and subsystems.
  • Research and respond to provider, customer service, provider representatives and other internal OHCA staff inquiries regarding coding/clinical claims editing and to resolve any medical authorization issues.
  • Interfaces directly with OHCA physicians on documentation and/or claims processing/prior authorization issues.
  • Collaborate with OHCA Care Management regarding members’ care to ensure coordination of overall Medicaid Care Management efforts.
  • Using clinical experience, acts as a resource to OHCA staff on claim resolution, system and/or policy-related issues. Act as medical authorization resource for OHCA personnel as well, regarding issues related to medical prior authorization.
  • Makes recommendations and assists in the development of new material and revisions to existing material for various OHCA publications and documents (e.g., SoonerCare Provider Manual, Billing and Procedure Manual, provider letters, provider contracts, etc.). Ensures that these materials are in accordance with existing State and Federal regulations.
  • Provides training and assistance with interpretation of existing policies, development of new policies, and claims processing issues. Interfaces with public, legislative and health care stakeholders and disseminates statistical, educational, and informational materials, as directed.
  • Schedules, arranges and participates in internal and external meetings.
  • Other duties as assigned.
Preferred Requirements:
  • Bachelor’s degree in Nursing AND
  • Current/Valid RN license AND
  • 3 years of clinical experience and experience in health care monitoring (e.g., quality assurance, surveillance and utilization review, auditing, health policy), clinical coding, and reimbursement, clinical review of claims and claims auditing.
  • Experience using database applications
Preference May Be Given To Candidates With:
  • Medicaid experience
  • Certified Professional Coder (CPC)
  • Managed care experience
  • Utilization experience
  • Policy development experience
  • Quality assurance/improvement experience
  • Advanced health related education (e.g., MSN)
  • Related professional certifications
Additional Required Documents


   Important: You must submit all required documents to be considered for this position.
View All Job Announcements