MEDICAL ASSISTANCE PROGRAM REPRESENTATIVE 22501

9/1/90 B

This is the first class in the Medical Assistance Program Representative series. Positions in this class represent the agency in consultations with hospitals, nursing homes, pharmacies, physicians, individual providers, and medical associations to explain and encourage compliance with provisions of the Title XIX Medical Assistance program. Duties include continuous liaison with providers to disseminate information; audit records; resolve claims, billing, supplemental payments, adjustments, and related matters; conduct special investigations of alleged abuses; and correct invoices pertaining to services provided to recipients. This class is distinguished from the Medical Assistance Program Representative Supervisor by the latter's responsibility for oversight of a single program component.

Complexity of Work: Performs work of moderate difficulty which involves disseminating program policy, procedure, claims, billing and other information to health care providers, recipients and others. Researches issues in response to inquiries and prepares oral or written responses on covered services, eligibility, claims adjudication, billing formats, State and Local Hospitalization, dental services, baby care, respite and adult day care, catastrophic health care, prosthetics, ventilator dependent children, vision, invoices, transportation, personal care, rehabilitation and other programs. Identifies program deficiencies through provider, recipient and other agency inquiries and recommends improvements to management on the operations and integrity of a number of health care programs administered by the agency. Plans, organizes and conducts provider seminars and provides technical assistance through procedural interpretation on claims, covered services issues and federal and state health care policies and procedures. Analyzes and evaluates provider manuals for clarity nd recommends changes by preparing and editing provider manual updates, procedural changes, recipient notices and memoranda for submittal to senior level management for approval and for distribution to providers and other interested parties. Evaluates provider manual changes and determines overall impact on other existing provider manuals and recommends changes as needed. May coordinate printing and mass mailing of provider manuals, policies and information communication. May develop, conduct and evaluate training needs assessments to identify specific provider or agency staff training needs. Prepares audio-visual materials for presentations to health care providers, professional and community organizations and others.

Supervision Given: Supervision is typically not a factor.

Supervision Received: Receives direction from a Medical Assistance Program Representative Supervisor or higher level section supervisor or manager.

Scope: Positions provide a variety of service assistance to both oral and written communications to providers and recipients by guiding in the interpretation of policies and procedures and presentation of information.

Impact of Actions: Oral and written communications provided have a significant impact on the application of medical assistance policies and procedures by health care providers and recipients and other agencies. A significant cost in time and recipient and provider goodwill may be incurred through errors in judgment.

Personal Contacts: Frequent internal and external contacts with health care providers, legislative staff, state, local and federal agencies, professional and community organizations, professional and technical health care and billing specialists, general public and vendors to provide information on medical assistance policies and procedures, respond to inquiries on Medicaid coverage and other issues, research issues, exchange health care information and promote the goals of the agency.

Knowledge: Working knowledge of medical and pharmaceutical terminology; health care payment systems; health care industry; health care policies and procedures; microcomputer, minicomputer and/or mainframe applications; and training and evaluation techniques.

Skills: Working skill in keyboarding.

Abilities: Demonstrated ability to interpret policies, procedures and regulations; communicate effectively orally and in writing; edit and format written communications such as procedures manuals and policy memos; organize work activities; plan and design training or informational materials; use independent judgment in making decisions about work related issues; direct health care providers in resolving problems; research and analyze data to reach logical conclusions; and to speak before diverse groups of varying size on health care policies and procedures.

QUALIFICATIONS GUIDE*

Licenses or Certification: None.

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

Level and Type of Experience: Experience in a social service or health care setting requiring the interpretation of policies and procedures.

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

This class specification is a revision of the Medical Assistance Program Representative class, effective September 1990.