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This is the third and supervisory class in the Health Care Compliance Program series for classes that review and analyze Medicaid billing and medical record data to identify abusive utilization of services by recipients and providers. Positions in this class supervise either the Provider Review, Recipient Monitoring or Recipient Audit programs. This class is distinguished from the Health Care Compliance Program Analyst Senior by its line supervisory responsibilities. It is distinguished from the Health Care Compliance Program Manager which manages all health care compliance programs for an agency.

Complexity of Work: Performs supervisory work of considerable difficulty. Supervises a staff of analysts and senior analysts and plans all activities performed by that staff including establishing unit priorities and strategies, assigning and reviewing cases, developing administrative procedures, and assessing staffing, equipment and system support needs of the unit to meet medical and financial audit objectives. Monitors and coordinates the Commonwealth's documentation of audit appeals issues and testifies at administrative appeals and hearings. Analyzes Provider Surveillance and Utilization Review Subsystem (SURS) database to meet Federal System Performance Review audit requirements. Coordinates the activities of the unit with other state agencies and with other units on case audit/review results. Writes, reviews and evaluates program policies and procedures to maintain effectiveness by encouraging program compliance.

Supervision Given: Provides supervision to a group of Health Care Compliance Program Analysts or Analysts Senior.

Supervision Received: Receives general directions from the Medical Assistance Program Compliance Manager who acts as primary resource on unusual claims processing or billing procedures case situations or in unusual case situations which might result in non-routine legal or governmental 1nquiries.

Scope: Provides management to the department's program compliance auditing an reporting activities. Supervises a staff of compliance auditors.

Impact of Actions: Decisions seriously impact the integrity of the Provider Review, Recipient Monitoring and Recipient Audit programs. Error or oversight could result in legal actions by providers or recipients against the department for financial recovery.

Personal Contacts: Frequent internal and external contacts with Office of the Attorney General, Commonwealth Attorneys, Department of Health Professions, the Medical Society of Virginia Review Organization, professional consultants, and all sections of the Department of Medical Assistance Services to provide information related to audits for compliance with state and federal regulations; to respond to requests for information; to request legal opinions, and to confer on policy problems.

Knowledge: Considerable knowledge of principles and technical methods of medical auditing and of the financial analysis of health care providers billing practices. Considerable knowledge of federal and state laws, regulations, and regulatory practices affecting the medical and business practices of health care providers; of department's policies for all provider types; and of current health care trends and community standards of practice.

Skills: None identified for this class.

Abilities: Ability to assess complex medical and financial audit issues and to accomplish audit program objectives; to interpret and explain complex statutes and regulations; to analyze computer generated reports and medical records in order to determine the appropriateness of billing and medical necessity of treatment; to communicate analysis orally and in writing through development of detailed written reports based on analysis; and to supervise.

QUALIFICATIONS GUIDE*

Licenses or Certification: None.

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

Level and Type of Experience: Considerable experience in medical utilization review, medical financial audits, peer review or related area. Work experience in a variety of clinical settings.

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 revised by the Department of Medical Assistance

Services, effective March 1991.