HEARING OFFICER/MEDICAL ASSISTANCE 21341

7/16/90 B

This is the first class in a series for professional positions responsible for conducting administrative hearings on appeals from applicants and recipients to the Department of Medical Assistance Services (DMAS). Positions in this class review case records in relation to applicable medical assistance policy and federal and state regulations, preside over fair and impartial hearings, deliberate evidence including complex medical data, and prepare the final decision in accordance with administrative law practice. This class is distinguished from the Hearing Manager/ Medical Assistance by the latter's responsibility for managing the work activities and performance of a staff of hearing officers, and the day-to-day operations of a hearing program.

Complexity of Work: Performs work of considerable difficulty in planning, coordinating, researching, analyzing, evaluating, and conducting Medicaid and state and local hospitalization hearings statewide. Positions in this class review and rule on decisions related to financial and categorical eligibility for medical assistance; state and local hospitalization; spousal impoverishment; Medicaid recipient disability; patient pay for nursing home care; as well as the denial, termination or reduction of hours for personal care services in nursing homes and state institutions; and appeals, including requests for placement in a rehabilitative facility outside the state; payment of preadmission screening for nursing home placement or personal care services; denial of transportation service or durable medical equipment; the assignment of one provider and one pharmacist due to excessive medical use; and the termination or reduction in nursing home or state institution personal care services for mentally ill or retarded patients. The work typically involves evaluating the priority of cases for validation and scheduling by contacting local social services agencies, local health departments or other units within DMAS to determine validity of appeal request, reviewing case records, resolving issues administratively, and supplementing the record to issue a judgment on the records. Conducts and presides over fair and impartial informal hearings where the issues involve financial and categorical eligibility for Medicaid and state and local hospitalization, directs the court reporter to administer oaths and affirmations, makes necessary inquires to develop the facts related to testimony, rules upon procedural matters, receives briefs and oral arguments, rules upon offers of proof and receives material and competent evidence, takes note of legal considerations, and rules upon motions. Evaluates evidence to reach factual findings, applies law, regulations, and policy to facts to make reasoned decisions researches cases, and prepares the final decision in accordance with administrative law practice.

Supervision Given: Supervision is typically not a factor.

Supervision Received: Direction is received from a Hearing Manager/Medical Assistance who reviews the hearing decision for accuracy, content and clarity.

Scope: Positions in this class affect the final determination on cases involving financial and categorical eligibility for Medicaid and state and local hospitalization by coordinating and presiding over hearings.

Impact of Actions: Erroneous decisions could result in financial or medical problems for recipients resulting in life threatening situations; denial of necessary therapy, personal care services, nursing home services, medical equipment; and litigation against the agency. The integrity and credibility of the program will remain viable by use of proper judgment in making decisions that comply with existing laws and regulations.

Personal Contacts: Frequent internal and external contact with local social services and health departments, the general public, physicians, attorneys, hospitals, nursing homes, elected officials, and the Office of the Attorney General to obtain and provide information related to appeals, issues and hearings.

Knowledge: Considerable knowledge of federal and state policies, procedures and regulations; methods of interviewing and controlling small groups in a social service setting. Working knowledge of the administrative procedures for conducting hearings.

Skills: None identified for this class.

Abilities: Demonstrated ability to analyze facts and policy, apply rules to facts to make a decision, communicate locally and concisely both orally and in writing, work independently, obtain information through a directed small group hearing, and manage a caseload to meet processing time limits.

QUALIFICATIONS GUIDE*

Licenses or Certification: None.

Education or Training: Graduation from an accredited college or university with course work in law, social work, and claims adjudication, or a related field.

Level and Type of Experience: Some experience in applying rules and facts to reach decisions and in interviewing from information such as eligibility determinations, courtroom law practice, and claim determinations; and in analytical writing such as policy analysis, report writing, law pleadings, or related activities.

An equivalent combination of training and experience indicating possession of the preceding knowledges and abilities may substitute for this education and experience.

This class was established as a result of a classification study by the Department of Medical Assistance Services and was edited and validated as a part of the Classification Review/Specification Update Program, effective July 1990.