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This is the fourth and managerial level class in the Health Care Compliance Program series responsible for planning and directing operations for the Program Compliance Division of the Department of Medical Assistance Services. Directs and manages administrative units including Provider Review, Recipient Monitoring, and Recipient Fraud and Recovery. These units are responsible for the Medicaid and State Local Hospitalization recipients and health care providers' program compliance activities. Manages the user activities of the Surveillance and Utilization Review Subsystem (SURS). This class is distinguished from the Health Care Compliance Program Supervisor which supervises one rather than all compliance programs for the agency.

Complexity of Work: Performs work of unusual difficulty. Plans and directs the activities of a major administrative division responsible for the detection, monitoring, auditing and investigation of Medicaid and State Local Hospitalization recipients and providers. The work typically involves budget development, employee relations management, planning and implementing section's policy, objectives and procedures. Designs and implements approaches for statistical audits. Coordinates activities of consultants in auditing and statistical application. Confers with state and federal officials in performance system reviews and evaluations relating to program compliance activities and computer subsystems. Responds to legal counsel representing providers or recipients on issues of administrative appeals procedures and settlements. Provides expert testimony for administrative, criminal and civil cases. Coordinates and maintains Post-payment Review liaison activities and procedures within the Department, Medical Society of Virginia Review Organization and other state agencies for the referral and management of program compliance activities.

Supervision Given: Provides direction to Health Care Compliance Program Supervisors, administrative staff, and a Compliance Investigations Supervisor.

Supervision Received: Receives administrative direction from the deputy director of administration who provides guidance on investigations of unusual complexity or political significance as well as instructions on system development projects.

Scope: Provides professional and administrative direction to a major agency division involving Medicaid and State Local Hospitalization program compliance activities. Manages a staff of supervisors involved with providing oversight to these activities.

Impact of Actions: Decisions made by this position wi11 have a serious impact on the effectiveness and efficiency of statewide provider compliance activities and Surveillance and Utilization Review Subsystem which effects Medicaid and State Local Hospitalization recipients, health care providers and the agency's public image.

Personal Contacts: Frequent contacts with Assistant Attorney General; Special Agency in Charge Drug Investigation Unit; Department of Health Professions; Office of the Inspector General, Health and Human Services; physicians, pharmacists and other health care providers; Secretary of Health and Human Resources; and Health Care Financing and Administration on case development, state assessment, coordination of investigation activities, resolution of audits and disagreement, and representation of the agency.

Knowledge: Comprehensive knowledge of Medicaid and State Local Hospitalization policy, procedures, and applicable federal and state statutes and regulations; of the health care industry and law enforcement; and of surveillance and utilization control procedures to include broad based knowledge of automated information systems.

Skills: None identified for this class.

Abilities: Demonstrated ability to manage, and to communicate effectively both orally and in writing.

QUALFICATIONS GUIDE*

Licenses or Certification:

Education or Training: Graduation from an accredited college or university with training in surveillance and utilization procedures.

Level and Type of Experience: Considerable management experience in a related health care delivery system with experience in third party insurance program compliance, auditing, surveillance and utilization review.

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 in February 1990. It was previously titled DMAS Compliance Program Manager.