Pharmacist - UAEN

You may hear the following types of cases as well as other cases that are under the jurisdiction of the SCDHHS Division of Appeals and Hearings:

• Adult and child disability.

• Nursing home/Waiver level of care.

• Tax Equity Fiscal Responsibility Act (TEFRA) childhood disability and level of care.

• Medicaid financial.

• Overpayment recoupment.

• Nursing home involuntary transfer/discharge.

• Nursing home audits.

• Provider payment.

• Provider exclusion/suspension.

• Beneficiary service denial/reduction.

• Managed Care Organization.

• Provider post-payment review.

• Hospital audits.



If you are not an attorney, you must have at least two (2) years of experience and knowledge in at least one of the areas listed below with correlated documentation and references. Preference is given to attorneys that have experience and knowledge in these areas:


1. Adult and childhood Social Security disability determination process including the sequential evaluation process.

2. Federal and State Medicaid Eligibility policy and procedures to include all categories of eligibility and the South Carolina level of care criteria for Medicaid nursing home sponsorship.

3. Federal requirements for nursing home involuntary transfer and discharges.

4. Federal and State Medicaid Managed Care Organization policy and procedures.

5. SCDHHS provider billing and enrollment policy.

6. Federal and State regulation and Medicaid policy regarding provider audit, post-payment review, exclusion, and suspension.


Duties

• To act in the capacity as an administrative hearing officer for SCDHHS for the purpose of conducting administrative hearings and preparing Orders and Final Administrative Decisions in accordance with the South Carolina Administrative Procedures.

• Draft, authenticate and publish Orders and Final Administrative Decisions in contested cases by accurately interpreting state and federal statutes, case law, regulations and policies, and applying them to specific findings of fact.

• Schedule and arrange hearing venues and travel to and conduct evidentiary hearings in accordance with the S.C. Administrative Procedures Act and SCDHHS’ regulations, while establishing a justifiable record by recording the proceedings and marking admissible tangible evidence. If live hearings are prohibited, schedule and conduct virtual hearings as directed by SCDHHS Chief Hearing Officer.

• Determine SCDHHS Division of Appeals and Hearings jurisdiction, develop and identify issues in controversy. Establish Findings of Facts and Conclusions of Law from documentary and testimonial evidence contained in the Record.

• Research and analyze a variety of laws, regulations, and case law along with program policies and procedures.

• In the event the petitioner in a case files a petition for further review with the South Carolina Administrative Law Court (SCALC), it shall be the responsibility to arrange for, review, and edit the transcript and prepare and certify the copies of the case record.

• The Contractor must attend in-house training as directed by SCDHHS regarding the Appeals process and any other training related to the South Carolina Medicaid program.

• In addition to the general requirements listed above, the contractor shall provide reliable transportation and internet connection.

Pay:

Consultant/1099 Based on complexity of each case.

About Capitol Bridge:
Founded in 2012, Capitol Bridge is based in Arlington, Virginia and is a SBA 8(a) Certified Small Disadvantaged Business with proven expertise providing independent medical reviews, records/data management services, medical coding, administrative staffing and eligibility reviews.