ADMINISTRATIVE LAW JUDGE/MEDICAL ASSISTANCE 21351

7/1/90 B

This is the first level class in a series for positions that adjudicate the final level of administrative appeal from applicants and recipients for the Department of Medical Assistance Services (DMAS). Positions render 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, and denial, termination or reduction of hours for personal care services in nursing homes or state institutions. Positions research complex state and federal laws and regulations including case law; review written briefs that present arguments on decision reversal; serves on the Medical Assistance Appeals Panel, and writes opinions on cases which present legal arguments used to formulate the decision of the Panel. This class is distinguished from the Administrative Law Judge Senior/ Medical Assistance by the latter's responsibility to manage the Medical Assistance Appeals Panel and to supervise a staff of DMAS Administrative Law Judges.

Complexity of Work: Performs work of considerable difficulty which requires the exercise of extensive legal abilities to develop binding decisions on higher authority appeals. Adjudicates appeals from applicants and recipients related to financial and categorical eligibility for medical assistance, State and Local Hospitalization, Spousal Impoverishment, Medicaid recipient disability, patient pay for nursing home care, and denial, termination or reduction of hours for personal care services in nursing homes or state institutions. In addition, appeals include requests for placement in rehabilitative facilities outside Virginia, payment of pre-admission screening for nursing home placement or personal care services, denial of transportation services or durable medical equipment, or 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 and retarded patients. The work typically involves conducting complex legal research on state and federal laws, regulations, and case law. This class analyzes decisions of DMAS Hearing Officers on lower level appeals; reviews fact situations to evaluate reasoning in applying the law and regulations to facts; participates in oral arguments; and reviews written briefs submitted by the appellant, representative, or attorney. Positions in this class serve as a voting member of a panel of Administrative Law Judges who provide the final level of administrative appeal; write opinions which will face close scrutiny in state and federal courts; make recommendations for possible changes to state regulations; prepare appeal manuals; and conduct legal training for hearing officers.

Supervision Given: Supervision is typically not a factor.

Supervision Received: Receives administrative direction from an Administrative Law Judge Senior/Medical Assistance who assigns cases for research and drafting of opinions. The class utilizes independent judgment to reach a decision on a case and refers to state and federal laws, regulations, case law, and medical assistance policies and procedures for reference in analyzing cases.

Scope: Positions in this class affect the conduct of complex legal research and interpretation of case laws on medical assistance programs and other applicable laws and regulations. This class analyzes lower level appeals decisions and determines their applicability to the law, written briefs, and oral arguments of appellants, representatives, and attorneys; conducts hearings as a part of a panel of Administrative Law Judges who make final agency decisions on appeals for a variety of medical assistance financial and categorical issues.

Impact of Actions: Incorrect decisions may cost recipients a service to which they are entitled under state and federal law or policy, which may result in life threatening situations. Errors in judgment may result in loss of public goodwill in the Medicaid/State and Local Hospitalization Program and the expenditure of substantial sums of money and time to defend legal actions. Sound decisions will ensure the appropriate and consistent application of agency policy.

Personal Contacts: Frequent internal and external contact with attorneys, State Assistant Attorney General, appellants, and state and federal legislators to provide legal information on policy applications and interpretations and to obtain information on cases under review.

Knowledge: Considerable knowledge of administrative law, legal research methodologies, law and regulations pertaining to medical and public assistance programs, and the administrative appeals process.

Skills: None identified for this class.

Abilities: Demonstrated ability to abstract rules of policy and law to facts; interpret medical data and policies, manage a caseload, meet strict deadlines, communicate effectively orally and in writing, and respond to public inquiries on laws, policies, and procedures related to medical assistance.

QUALIFICATIONS GUIDE*

Licenses or Certification: None.

Education or Training: Graduation from an accredited college or university with course work in business, public administration, law or a related field.

Level and Type of Experience: Considerable experience working with and interpreting relevant laws, rules and regulations and in conducting hearings.

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.