MEDICAID COST SETTLEMENT AGENT 23506

5/2/88 B

CLASS CONCEPT/FUNCTION

This is an advanced level class in a series for classes with positions responsible for acting as agents for the Commonwealth in mediating cost settlement claims from state¬wide institutional health care providers. Positions in this class typically solve discrepancies involving compliance or financial issues between provider claims for health care reimbursement and Medicaid audit findings.

DISTINGUISHING FEATURES OF THE WORK

Complexity of Work•: Performs work of considerable difficulty requiring analysis of non-recurring situations to establish precedents for evaluating Medicaid reimbursement issues. Mediates issues to preclude informal hearings. Presides over informal administrative hearings to render findings of fact and law. Develops case briefs for formal hearings. Conducts exhaustive legal research on reimbursement issues. Formulates and administers appeal regulations. Recommends reimbursement program revisions related to State legislation and providers' cost reporting practices.

Supervision Given: Supervision is typically not a factor.

Supervision Received: General direction is received from the Medicaid Reimbursement Division Director. Completed work is judged in terms of accomplishing reimbursement program objectives.

Scope: Variety of activities affect statewide payments to nursing homes, hospitals, and other institutional providers of health care.

Impact of Actions: Decisions regarding compliance and finance issues affect the amount of reimbursement institutions receive for providing health care to the medically indigent. Decisions also set a precedent for future financing of statewide health care.

Personal Contacts: Frequent contact with the Attorney General's office staff to assist in preparing for formal appeals and litigation and with health care providers' attorneys and certified public accountants for counseling on cost reporting practices established by law, regulation, or precedent. Some contact with members of the General Assembly when responding to inquiries on legislative proposals affecting Medicaid reimbursement to institutional providers of health care.

KNOWLEDGE, SKILLS AND ABILITIES

Knowledge: Considerable knowledge of principles and technical methods of finance, accounting and financial analysis applied to business organizations. Considerable knowledge of business accounting practices. Considerable knowledge of legal research methodologies. Working knowledge of the regulatory compliance process.

Skills: None identified for this class.

Abilities: Demonstrated ability to assess complex finance, accounting, and financial analysis issues; to preside over conferences or hearings involving contentious parties; to resolve issues of fact and law; and to communicate clearly orally and in writing.

QUALIFICATIONS GUIDE*

Licenses or Certifications: None.

Education or Training: Graduation from an accredited college or university with major course work in accounting, finance, or a related field.

Level and Type of Experience: Experience in conducting conferences or hearings involving issues of compliance or finance. Experience in dealing with Medicare of Medicaid reimbursement issues.

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

CLASS HISTORY

This is a new class established in September, 1986.