MEDICAL ASSISTANCE SERVICES SUPERVISOR 22504

3/1/90 B

This is the supervisory class in the Medical Assistance Program Administration series that manage utilization review activities related to individual Medicaid program areas such as hospital utilization review, long-term care, maternal and child health, home-based care, and rehabilitation. Positions in this class supervise the day-to-day operations of a unit engaged in the review and analysis of documentation related to the quality and level of health and social services care rendered to Medicaid recipients by health care providers, severity of illness and intensity of service for acute care, compliance with state and federal regulations governing hospital utilization review plans, patient assessments for enrollment and pre-admission screening. Additionally, positions in this class are responsible for overseeing payment authorizations for Medicaid services, developing and conducting provider training programs and recommendations on provider contracting of services.

Complexity of Work: Performs work of considerable difficulty in supervising, monitoring and evaluating the work of a unit composed of program utilization review and senior analyst staff. Evaluates and analyzes staff utilization review reports and acute care utilization review processes to determine if follow-up meetings with providers or individual recipient cases are needed, if recommended corrective action is appropriate, or if modifications in regulations and policies are necessary. Confers with Medicaid consultants in medicine, psychiatry, psychology and pharmacy to ensure the safety, health and welfare of recipients. Develops and supervises the implementation and monitoring of reports, provider and recipient regulations, policies and procedures and Medicaid utilization review policies and procedures. Plans, supervises and monitors the development and implementation of special projects, studies and reports. Researches and interprets state and federal regulations, policies, procedures and guidelines to health care providers and staff within the agency's operating divisions. Serves on state level councils, committees and task forces related to the assigned Medicaid area of responsibility. Develops training materials and plans and conducts training on Medicaid policies, procedures and programs for Department of Medical Assistance Services staff, state and local agencies, health care providers, advocacy groups and other organizations. Researches and drafts written responses to inquiries by external sources. Recommends program or policy changes to management. May compile and evaluate statistics on pending hospital lengths of stay claims by number of claims denied or approved and on utilization of services to identify irregular patterns or trends. May perform studies on the effectiveness of the hospital utilization review process through analyses of the percentage of claim denials for each hospital on a monthly, quarterly and annual basis; may testify at informal hearings and appeals on adverse decisions regarding hospital lengths of stay claims.

Supervision Given: Provides supervision to a staff of Utilization Review Analysts and Utilization Review Analysts Senior and program support staff engaged in performing utilization review and related administrative and support activities.

Supervision Received: Receives general direction from a higher level section manager.

Scope: Positions in this class affect agency-wide operational, administrative and service activities impacting on health care providers and recipients and organizational and objectives.

Impact of Actions: Work has a direct and serious impact on management decisions relating to agency goals, objectives and strategies and on the effective utilization of human resources to ensure accomplishment of program goals. Supervisory responsibilities have a direct impact on subordinates ability to carry out utilization reviews and on the long-term financial, political and public relations interests of the agency.

Personal Contacts: Frequent internal and external contacts with health care providers, recipients and their families, other state and federal agencies, the Health Care Financing Administration and the Office of the Attorney General to provide and obtain information related to the program, resolve problem issues and respond to inquiries.

Knowledge: Considerable knowledge of professional standards of care for health care programs; needs of the elderly, children, disabled, mentally ill, mentally retarded and others with special health care needs; health and social service programs and issues; state and federal health care and social services regulations; community resources and volunteer agencies; information systems; medical terminology; medical standards of treatment; negotiation techniques; project management; and supervisory principles and practices.

Skills: Working skill in keyboarding.

Abilities: Demonstrated abilities to supervise the work of subordinate staff; analyze data and reach logical conclusions; organize and prioritize work assignments; direct staff in problem resolution; manage special projects; draft budget amendments; prepare feasibility reports; conduct staff and other meetings; make presentations before a variety of groups having diverse needs; and to communicate effectively orally and in writing.

QUALIFICATIONS GUIDE*

Licenses or Certification: None.

Education or Training: Graduation from an accredited college or university with course work in a social services or medical discipline or with studies in hospital, business or public administration.

Level and Type of Experience: Experience in leading or supervising utilization review and quality assurance activities and program development, implementation and training in a social services or health care environment.

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 was revised by the Department of Medical Assistance Services, effective March 1, 1990.