2/1/90 B

This is the first class in the Health Care Compliance Program series for classes that review and analyze Medicaid billing and medical record data to identify abusive utilization and mis-utilization of services by recipients or providers. This class is responsible for analyzing recipient services with the authority to implement restrictions of recipients to designated health care providers to control excessive utilization. Positions in this class audit medical records by analyzing and evaluating automated paid claims histories, recipient surveillance and utilization review reports and medical records and conferring with health care providers to determine the appropriateness of utilization and the necessity, quality and reasonableness of patient care. Additionally, positions in this class determine recipient case action to be taken in accordance with state and federal restricted recipient procedures (client medical management where the recipient is restricted to one physician and one pharmacy for provision of medical services to reduce abusive practices) and implement a corrective action plan. This class is distinguished from the Health Care Compliance Program Analyst Senior class which conducts both medical and financial audits on provider records.

Complexity of Work: Performs work of moderate difficulty in the identification of abusive utilization practices by recipients in the Medicaid Program and the implementation of restrictions of recipients to designated health care providers to control excessive utilization. Reviews and analyzes Medicaid billing and medical record data for recipients by evaluating automated paid claims histories, Recipient Surveillance and Utilization Review (SURS) reports and information provided by local social service agencies or other informants and confers with Medicaid providers to determine the appropriateness of utilization of health care services and the necessity, quality and reasonableness of patient care. Documents findings on agency review forms and other documentation and independently determines case action to be taken in accordance with established restricted recipient methodologies. Presents oral and written recommendations

for recipient restrictions to the agency's medical consultant for final approval. Implements the corrective action plan for improper or abusive practices by notifying the recipient of the recommendations to modify excessive or improper utilization; notifying primary health care providers and local social service agencies to explain agency action and/or recommendations for change in the recipient's utilization patterns; establishing the method and schedule for individual case monitoring as needed; initiating the mailing of a restriction package to recipients with instructions to select primary heath care providers; selecting primary providers for recipients who refuse to select or are unable to locate primary providers. In addition, evaluating the use of non-designated providers and/or use of emergency room services during restriction through medical record review or contacts with providers; and, investigating, analyzing, and approving requests for primary provider changes in cases involving complex issues of adequacy or appropriateness of medical treatment by the provider and presenting recommendations for denials to the agency medical consultant for final approval. Provides guidance to providers on client medical management policy and procedures and takes necessary actions to resolve referral and mediates with providers and recipients to correct problems related to client medical management policy. Refers fraudulent utilization or unusual billing practices to appropriate DMAS work units for further investigation. Develops detailed case summaries of actions taken with justification for agency action and prepares supporting documentation for recipient appeals. Testifies in recipient appeals proceedings. Maintains an automated monitoring system to track caseload activities. Develops and conducts client medical management procedures training sessions and develops informational materials for local social service workers. Prepares special reports and projects and conducts special investigations for program evaluation and management as assigned by unit supervision. Develops recommendations of client medical management policies and procedures. Develops monthly statistical reports on caseload activities. Represents the unit through participation at conferences, meetings and special speaking arrangements. May function as a resource person on medical illnesses and associated treatments, health care practices, medications and procedures and may develop ,medical resource materials.

Supervision Given: Supervision is typically not a factor.

Supervision Received: Receives directions from the Medicaid Compliance Supervisor in the form of general assignments and periodic evaluations of the work.

Scope: Positions in this class identify and control abusive utilization practices by recipients which affect program integrity,

recipient access to Medicaid health care providers and services on a statewide basis and provider relations.

Impact of Actions: Decisions on Medicaid recipient abusiveness of use of services and implementation of restrictions to designated health care providers significantly impact on cost avoidance, compliance with Systems Performance Review (a federal program compliance requirement), quality of health care provided to recipients and relations with health care providers. Errors in judgment may result in the non-detection of recipient and/or provider fraud and abuse, legal actions by recipients and/or providers, federal financial penalties, poor relations with recipients and providers and negative public opinion of the agency.

Personal Contacts: Frequent internal and external contacts with health care providers to include physicians, hospitals and pharmacies, Medicaid recipients, local Departments of Health and Social Services, attorneys and Legal Aid to discuss recipient utilization of services, behavioral patterns, medical regimens and referrals, verify medical and emergency room records, gather information, provide training on procedures, provide information on emergency use for non-designated providers, clarify client medical management program policies and restrictions. explain the recipient appeals process and discuss referrals to the program.

Knowledge: Working knowledge of general medical treatment procedures and practices, medical terminology, health care issues, human behavior patterns and the impact of illness on human behavior, and utilization review and quality assurance methods.

Skills: Working skill in the operation of a CRT, minicomputer, microcomputer and/or mainframe applications.

Abilities: Demonstrated ability to analyze automated utilization reports and medical records to determine appropriateness of utilization of health care services and medical necessity of treatment; communicate effectively orally and in writing; develop detailed reports of utilization review findings based on independent analyses; conduct evaluations and analyses of health care data and reach independent decisions and logical conclusions; and work independently.

QUALIFICATIONS GUIDE*

Licenses or Certification: None.

Education or Training: Graduation from an accredited college or university with major course work in nursing, quality assurance, or a related field.

Level and Type of Experience: Experience in utilization review or a comparable program.

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

This class was established as result of an agency-wide organizational study in February 1990.