Owns policies and procedures process. Collaborates with all departments on materials related toMedicaid. Submits contracts to the NYS DOH. Submits member facing materials to the NYS DOH. Submits member provider materials to the NYS DOH. Works with RR Donnelly for mass mailings and creativematerials. Submits programs to the NYS DOH. Trained in SERFF.

Assists senior managers in the Division of Long-Term Care,Bureau of Managed Long-Term Care (MLTC) in a broadrange of planning, implementation, reporting evaluationand surveillance activities. Leads efforts in the development of medical policyguidelines, procedures, and documentation to facilitateprogram operations. Assists in the evaluation of Medicaid legislation andprograms. Reviews periodic and final reports of grant and contractactivity for funds given to service providers by theDepartment of Health for specific services anddemonstration projects. Provides development, training and technical assistance toproviders and other stakeholders. Supervise staff, as appropriate. Develops tools to track oversight of providers to ensurecompliance with Medicaid contract. Conducts interviews with Healthcare Plans to clarifydiscrepancies with documentation.

Conducted interviews with Healthcare Plans to clarifydiscrepancies with documentation. Performed prior authorization review of scheduledinpatient surgeries, outpatient surgeries, DMEs, hospice,radiology, and therapies. Performed utilization review for emergency admissions. Evaluated medical guidelines and benefit coverage todetermine appropriateness of services. Devised or identified solutions for irregular requests andissues. Supervised and maintained all utilization reviewdocumentation through ECC and WMDS. Performed admission reviews based for medical necessitybased upon MCG and AIM specification. Served as subject matter resource, providing informationrelated to medical review situations. Submitted cases to Medical Director for criteria failures andhelped facilitate resolutions and approvals. Successfully led key projects resulting in 30% decrease ofcases.

Kept accurate log of all requests for medical informationand records. Managed system conversion and maintained minimaldowntime during updates. Utilized Allscripts to manage and confirm patient data, suchas insurance, demographic and medical historyinformation. Reviewed charts and flagged incomplete or inaccurateinformation.