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Supervises and performs duties related to the review and investigation of Medicaid claims which involve out-of-state services, third-party liability, fraud and transportation payments.

The work involves considerable personal contact with individual and institutional services providers, recipients, attorneys and other parties in the resolution or certain special problem matters in the Medicaid Program. Supervision is exercised over a staff of clerica1 and accounting clerical personnel who perform the daily review and processing of claims from out-of-state service providers and from in-state agencies which transport Medicaid recipients. The subordinate staff also handles daily mail and supply distribution and related support activities for the Virginia Medical Assistance Program. As problem situations are identified during the claims processing work, including suspected instances of fraud or liability of a third party for medical services rendered to Medicaid recipients, visits are made to the areas of possible discrepancy to obtain first-hand information about the situations and to attempt to bring them to satisfactory conclusions. Liaison is maintained with the Office of the Attorney General and with law enforcement agencies in order to assist with the investigation and preparation for those cases which inquire into more complex questions concerning the providing of services to Virginia Medicaid patients by providers in other states or the approval of new provider applicants whose qualifications are questionable. Direction is received from the Medical Assistance Program Administrator.

Examples of duties characteristic of positions in this class:

1. Develops and supervises the implementation of procedures for the

timely and accurate processing of claims from out-of-state

providers of care to Virginia Medicaid recipients, and from all

cities and counties within the State regarding the payment of

recipient transportation expenses; ensures the verification of

eligibility in each case and the establishment and maintenance of

necessary files to substantiate payments; oversees the

maintenance of expenditure and allotment records for each

locality.

2. Coordinates the receiving of inquiries from medical facilities

in other states regarding the admission or proposed admission of

Virginia Medicaid recipients; supervises the verification of

eligibility of recipients, and the communication by telephone or

letter the response to the inquiries; conducts more detailed

investigations in those cases involving significant questions of

propriety or validity.

3. Develops and implements policies and procedures concerning the

detection or determinations of fraud and third party liability;

establishes contact with providers, recipients, agencies and

attorneys in cases such as accidental injury of Medicaid

recipients where there is a likelihood that someone other than

Medicaid is liable for the medical costs involved; works with an

Assistant Attorney General and law enforcement officials in

instances where fraud or third-party liability is indicated but

has been contested.

Graduation from an accredited college or university and two years of administrative experience which provided a knowledge of the management of public health programs or medical care facilities. Graduate study in public health or hospital administration may be substituted for the experience or additional related experience may be substituted for the education on an equivalent time basis.

Considerable knowledge of the principles and practices of public health and medical care administration; knowledge of accounting and auditing procedures; ability to interpret and apply provisions of pertinent statutes, rules and regulations; ability to work well with individuals and professional groups; ability to plan and supervise the work of others.