MEDICAL REVIEW ANALYST
New Jersey treats Medical Review Analyst as a competitive-class job, so the gate is an examination and the ranked list it produces rather than a direct offer.
The spec names a master's degree, but it leaves the door open to substitute experience for the degree. The FY 2027 range lands between $83,582 and $122,832, and state payroll currently lists about 25 people in the title, most of them at Office of State Comptroller.
How to apply
This title is filled by competitive examination.
See every real route in, and where to apply. 2 agencies employ it. We don't track live vacancies.
See all 2 employers and how to apply →Who employs this title
Medical Review Analyst appears on the State payroll at 2 departments, most of them at Office of the State Comptroller.
State departments
| Employer | Employees |
|---|---|
| Office of the State Comptroller | 16 |
| Department of Human Services | 9 |
State payroll and independent authority payroll are separate systems and are never merged. See data sources.
Who employs this title
State payroll records show 25 people working under this title. The median actual salary is $118,678. The agencies employing the most are:
- Office of State Comptroller (16)
- Human Services (9)
Counts from NJ YourMoney agency payroll. See statewide workforce analytics.
Official job specification
The text below is the official specification published by the New Jersey Civil Service Commission. The plain-language summary and analysis above are derived from it by NJ Civil Service Navigator. Source: the official specification page at NJ CSC.
Definition
Under the direction of a Supervising Medical Analyst or other supervisory officer in the Division of Medical Assistance and Health Services, Department of Human Services, reviews, analyses, and evaluates surveillance reports, and conducts investigations of provider and recipient utilization practices for purposes of determining the quality and necessity of medical services reimbursed by the New Jersey Medicaid Program; does related work as required.
Examples of work
Ascertains through computerized reports and other information sources of potential third party liability situations such as Tort and other insurance, as well as probate and voluntary repayment matters. Determines and initiates procedures to effect recovery of all funds improperly or incorrectly expanded by the program. Reviews and analyses recipient utilization reports to determine those expenditures which are casually related to third part liability matters. Communicates and asserts claims in compliance with appropriate state and federal laws to tortfeasors, insurance companies, legal representatives, or executors and administrators of estates. Controls the continued development and monitoring of all factual, pertinent and related material within the scope of recovery actions. Establishes and maintains liaison with representatives of estates, attorneys, insurance companies, and other interested persons relative to litigated matters; secures required information and reports from public agencies, discovery proceedings, and court records. Prepares clear technically sound, accurate, and informative statistical, financial, investigative and other reports containing findings, conclusions, and recommendations. Conducts settlement negotiations with attorneys in accordance with applicable law and regulations; confers with counsel assigned by the Office of the Attorney General to represent the Division in litigation; prepares case materials for referral to the Attorney General's Office and testifies at court trials and administrative hearings when so assigned. When necessary, attends conferences and discussions with attorneys and insurance companies, the factual or legal questions involved in disputed issues. Confers with, and/or visits county welfare agencies, and providers to discuss their roles in Medicaid recovery matters. Processes claim files, and is responsible for disposition of assigned cases. Receives and acknowledges monies pursuant to case activity; transmits same for deposit with instructions as to appropriate disbursement. Analyses case files to initiate exclusion of providers from program participation; prepares exclusion letters for Division Director's signature. Recovers monies inappropriately paid in fraud and abuse situations; also recovers monies due the Pharmaceutical Assistance to the Aged and Disabled and Lifeline Programs. Summarizes case file findings regarding provider procedural code and medical record-keeping compliance, and medical necessity, and quality of care. Confers with Bureau of Medical Care Surveillance and the Medicaid Fraud Section of the Division of Criminal Justice regarding liability. Reviews audits referred by the Department of Human Services' Office of Auditing involving the area of long term care facilities. Implements the recovery process regarding recipient, ambulatory care and long term care overpayments, including the assessment of interest, treble damages, and false claim penalties where appropriate. Schedules and conducts Unit prehearing conferences involving aberrant providers, their attorneys, accountants, consultants, and occasionally including the Deputy Attorneys General from the Division of Law. Conducts reviews of assigned cases of recipients who have indicated patterns of irregularity or misutilization of Medicaid services. Checks and reviews available data sources such as recipient profiles, data base and other microfilm/microfiche data to determine number of services provided, frequency of provider visits, types of prescriptions, different diagnoses and number of different pharmacies utilized; compiles, analyzes, and summarizes obtained data, and makes recommendations for appropriate sanctions or other actions. Confers with Division pharmaceutical, physician, dental, or other relevant professional staff for expertise needed in assessing salient case materials. Confers with and/or counsel recipients regarding their Medicaid services utilization. Confers with municipal, county, or state law enforcement personnel in certain cases of recipient fraud or abuse. Identifies appropriate recipients for restriction and/or issuance of "warning" Medicaid cards. Assists the Supervising Medical Review Analyst in developing parameters for the Recipient Dispersion Report (a computerized list compiled by the Department of Treasury.) Develops and maintains follow-up activities to insure effective restriction activity, maintains liaison with Blue Cross and County Welfare Agencies in this function. Assists in developing written procedures and makes recommendations to Supervising Medical Review Analyst to improve efficiency and productivity. Monitors recipients on Special Status to determine time frames of restriction, and consideration for termination after reasonable period of time as required by Federal regulations. Responds to problems related to provider payments in areas involving denial of payment for services to Special Status recipients; determines if payment is indicated and arranges for such payment. Performs field investigations involving both institutional and non-institutional providers, e.g., nursing homes, hospitals, and ambulatory care providers. Implements new policies and procedures resulting from legislation such as the bed-hold program, private pay contracts and long term care facilities. Assists the Bureau of Management Information System in developing software in order to provide more detailed reports. Compares patient charts in the provider's office with claims submitted to Medicaid. Represents the Division in connection with providers; instructs providers concerning program policies and regulations. Reviews provider computer print-outs using specific parameters; compares similar providers in an effort to identify cases which require investigation. Works with Medical Consultants in analyzing parameters, trends of service, class groupings, and categories of service. Reviews prescription diagnosis, contacts physicians on recipients to determine possible abuse or fraud. Assists in the selection of providers and recipients to analyze profiles for fraud and abuse on a quarterly basis. Functions as a liaison between the Division's Medicaid Management Information System Advisory Committee and the fiscal agent Blue Cross and Prudential Insurance Company; instructs their staff in the interpretation and analysis of Surveillance Utilization Review Sub- Systems reports; acts as a resource person to keep said staff current with Division activities; provides accurate data base information regarding recipient eligibility, provider activity, and Surveillance Utilization Review Sub-Systems data which may impact on Division policy. Acts as liaison between the Surveillance Utilization Review Sub- Systems Review Unit and the Division Consultants in relation to Medicaid Management Information System activities; instructs physicians, pharmacies, contractor liaisons, optometrists and other key personnel in the use of Surveillance Utilization Review Sub-Systems management reports; participates in Medicaid Management Information System Advisory Committee along with Division representatives to show how Surveillance Utilization Review Systems data may impact on Division policy. Participates as a member of Medicaid Management Information System Advisory Committee to report current guidelines, regulations and information relative to the annual Systems Performance Review conducted also takes part in the research and evaluation of Surveillance Utilization Review Sub-Systems activity, discusses technical matters, findings, and recommendations. Conducts quarterly analyses of a percentage of excepted providers and recipients; prepares clear and concise reports of such analyses containing findings, conclusions, and recommendations; conducts needs assessments with Division management representatives to develop information systems pertinent to their needs. Plans and develops parameter changes for exception processing to determine aberrant patterns by both providers and recipients; instructs Bureau of Medical Care Surveillance medicaid review analysts in the interpretation of Surveillance Utilization Review Sub-Systems data. Works with the Bureau of Management Information Systems to develop accurate Surveillance Utilization Review Sub-Systems reports that reflect Medicaid provider and recipient activity. Assists the Unit Supervisor in preparation of documentation for Systems Performance Review requirements. Sends Explanation of Medicaid Benefits questionnaires to recipients to identify potential fraud or abuse warranting investigating. Maintains the essential files and records. May be required to learn to utilize various types of electronic and/or manual recording and information systems used by the agency, office, or related units.
License
Appointees will be required to possess a driver's license valid in New Jersey only if the operation of a vehicle, rather than employee mobility, is necessary to perform the essential duties of the position.
Knowledge, skills and abilities
Knowledge of the problems to be encountered in the investigation of the utilization practices of providers of health services and recipients. Knowledge of interviewing techniques. Ability to acquire knowledge of the internal organization, programs, responsibilities, policies, standards, and procedures of the Division of Medical Assistance and Health Services and the Department of Human Services, and the pertinent state and federal statutes and regulations applicable to the New Jersey Medicaid Program. Ability to acquire knowledge of the various agencies within the U.S. Department of Health and Human Services and their inter- relationships with state governmental agencies and health programs. Ability to acquire knowledge of the various agencies of the registration, approval, and/or certification of health care personnel, medical facilities, and related health services. Ability to learn to utilize various types of electronic and/or manual recording and information systems used by the agency, office, or related units. Ability to read, write, speak, understand, or communicate in English sufficiently to perform the duties of this position. American Sign Language or Braille may also be considered as acceptable forms of communication. Persons with mental or physical disabilities are eligible as long as they can perform the essential functions of the job after reasonable accommodation is made to their known limitations. If the accommodation cannot be made because it would cause the employer undue hardship, such persons may not be eligible.
Note
Applicants must meet one of the following or a combination of both experience and education. Thirty (30) semester hour credits are equal to one (1) year of relevant experience. Seven (7) years of professional comprehensive experience in work involving the review, analysis, investigation, and/or authorization of medical care services in a large agency or organization responsible for the provision and/or payment of health services. OR Possession of a bachelor's degree from an accredited college or university; and three (3) years of the above-mentioned professional experience. OR Possession of master's degree in Health Administration, Hospital Administration, Public Administration or Business Administration; and two (2) years of the above-mentioned professional experience. "Professional experience" refers to work that is creative, analytical, evaluative, and interpretive; requires a range and depth of specialized knowledge of the profession's principles, concepts, theories, and practices; and is performed with the authority to act according to one's own judgment and make accurate and informed decisions.