HEALTH CARE REIMBURSEMENT SPECIALIST 22201

12/01/93 B

This is the single class in the Health Care Reimbursement Specialist series that develops comprehensive Medicaid and other indigent health care reimbursement methodologies, policies, procedures and legislation. Positions in this class serve as project leaders on internal and external task forces designing new health care reimbursement strategies and alternative delivery systems and serving as a resource to the legislature on indigent health care studies.

Complexity of Work: Performs work of unusual difficulty related to the development of complex methodologies and strategies for reimbursement of Medicaid and other indigent health care program services to institutional providers such as hospitals and nursing homes, non-institutional providers such as physicians and clinics, Department of Health clinics and other providers. Identifies reimbursement strategies designed to contain costs through cost benefit analysis and to meet challenges by health care providers and others in a legal setting. Determines the fiscal and service impact of reimbursement methods by analyzing fees, per diem or alternative strategies. Designs, develops, implements and evaluates statistical models on reimbursement for the purpose of program evaluation, budgetary impact determination and long-range planning of services to Virginia's indigent population. Conducts reimbursement studies in a variety of settings such as on an international, national, local government and private sector basis to determine the relation of such reimbursement systems to Medicaid and other indigent health care programs. Analyzes and evaluates existing reimbursement regulations and policies to develop and propose revisions that improve the efficiency and effectiveness of indigent health programs and ensure compliance with state and federal law and regulations. Prepares detailed analytical reports on the impact of new federal legislation on reimbursement, on trends in health care reimbursement, comparisons of Virginia's reimbursement method with other states', with the health care industry in general and on other related issues for legislative study groups and the agency head. Develops procedures and guidelines for reimbursement implementation plans. Prepares amendments to the State Plan to identify reimbursement implementation plans and recommends changes to the State Plan. Drafts legislation relating to reimbursement. Provides professional consultation to the Governor's Office, Secretary of Health and Human Resources, the legislature, the agency head, the pharmaceutical association and others on reimbursement issues and serves as project leader on intra- and inter-agency task forces developing new reimbursement methodologies and alternative health care delivery systems to enhance client access to health care services and to keep indigent health care programs effective.

Supervision Given: Supervision is not typically a factor for these positions, however they serve as a project leader on health care reimbursement task forces by establishing project goals and directing project team activities.

Supervision Received: Receives administrative direction from a Medicaid Division Director. Positions are free to plan, develop and organize all work activities and establish policy parameters.

Scope: Positions in this class design and develop complex health care reimbursement methodologies, strategies, plans and policies that affect the agency's system and method of reimbursement for Medicaid and other indigent health care program services to institutional, non-institutional, Department of Health clinics and other health care providers.

Impact of Actions: The development of reimbursement methodologies, strategies and policies seriously affect the state budgeting and cost for payment of health care services provided to Virginia's indigent population. Errors in judgment may result in significant costs to the state, legal action by health care providers and others, non-compliance with federal regulations, loss of federal funds and negative publicity for the agency.

Personal Contacts: Frequent internal and external contact with a variety of governmental sources, associations, health care providers and others on issues related to reimbursement strategies, legal requirements for reimbursement, policy trends, health care delivery systems and reimbursement studies and consultation.

Knowledge: Comprehensive knowledge of Medicare/Medicaid cost reimbursement principles and related hospital and nursing home accounting practices. Considerable knowledge of health care programs and organizations of health care agencies; research and budgeting techniques and principles used in planning study projects; government process of the development of regulations and laws; quantitative and qualitative statistics and statistical projections; and econometrics.

Skills: None identified for this class.

Abilities: Demonstrated ability to analyze descriptive and inferential statistics and actuarial statistical data and compose reports; to communicate effectively orally and in writing; and work with others to complete studies and reports.

QUALIFICATIONS GUIDE*

License or Certification: None.

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

Level and Type of Experience: Considerable experience conducting policy development, long-range health care planning, analysis of requirements for health care delivery systems including reimbursement methodologies and strategies, providing consultation to governmental groups and leaders and leading project groups performing comprehensive health care studies.

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 December 1, 1993.