Description
Duties Description
The Division of Medicaid Investigations (DMI) vigilantly monitors the Medicaid program for program integrity. DMI staff responds to detected fraud through agency actions to deter fraudulent behavior and remedy program vulnerabilities. The Recipient Restriction Program (RRP) coordinates medical services and improves quality of care for Medicaid recipients. Coordination of care reduces the potential over-utilization of health care services and prevents abusive or fraudulent behavior. The Pharmacy Consultant will work with other individuals on the State Medical Review Team (SMRT) within the RRP of DMI.
The SMRT performs comprehensive utilization reviews of a recipient's Medicaid services. The RRP may restrict the recipient to care provided by, or referred by, a Primary Care Provider, Inpatient Hospital, and/or Primary Pharmacy. A restriction is implemented if it is found that the recipient has received duplicative, excessive, contraindicated, or conflicting health care services, drugs, or supplies, or if a recipient commits fraudulent acts with their benefit card (i.e., forged prescriptions, card loaning, doctor shopping). As a member of the SMRT, the incumbent for this position will review individual Medicaid recipients to determine whether they should be recommended for restriction. Individual recipients are chosen for medical review through profile reports obtained by running exception criteria against Medicaid paid claims data, or by referrals from outside sources. The Pharmacy Consultant will be responsible for preparing written narratives detailing the pharmacological history of paid Medicaid claims to determine overuse or misuse of services warranting the restriction of the recipient.
Other Duties Will Include, But Not Be Limited To
- Making referrals to other units within DMI when information of interest is found in the process of conducting reviews, such as forged prescriptions, inappropriate ordering by providers, and illegal or otherwise inappropriate actions by the recipients to increase the overall integrity of the Medicaid program
- Updating and/or developing criteria to identify fraud, waste, and abuse within the Medicaid program.
- Ensuring RRP compliance is maintained by the Medicaid Managed Care Organizations (MMCO) and Local Departments of Social Services (LDSS).
- Ensuring access to care for restricted recipients through communication with providers, MCOs, and other agencies.
Current State Employees
Minimum Qualifications
Possession of license and current registration to practice pharmacy
in New York State and eligible to transfer under section 52.6 or 701.
Non-state Employees
Possession of license and current registration to practice pharmacy
in New York State, and two years of post-licensure experience.
Additional Comments
Free parking is available.
The agency participates in the NYS Telecommuting Program and questions may be raised during the interview. Employees are required to apply to obtain approval through management to telecommute according to the agency's Telecommuting Program.
The Office of the Medicaid Inspector General is proud to be an equal opportunity employer. We encourage those with unique backgrounds and contributions such as education, culture, ethnicity, race, sex, gender identity and expression, nation of origin, age, languages spoken, veteran’s status, color, religion, disability, sexual orientation, and beliefs to apply.
We provide reasonable and religious accommodations for any part of the application and hiring process. If you have a disability or special need that requires accommodation, please send a request to RARequest@omig.ny.gov.
