MEDICAID REIMBURSEMENT AUDIT MANAGER 23507

4/1/90 A

This class is the managerial level in a series of classes for positions responsible for auditing the financial operations, financial condition, and regulatory compliance of institutional health care providers or supervising a mediation of cost settlement claims for statewide institutional health care providers. Positions in this class are responsible for managing and developing audit programs or reimbursements from institutional providers. By emphasizing program integrity, incumbents of the class maintain uniform application of health care auditing or Administrative Processes Act and applicable state and federal laws, regulations and policies relating to institutional reimbursement appeals. The class is distinguished from the Reimbursement Audit Supervisor by its focus on program development and monitoring rather than on daily operational issues.

Complexity of Work: Performs work of unusual difficulty by conducting independent analysis of institutional reimbursement appeal decisions or designing methods for examining and auditing financial records of health care providers. Positions related to appeal proceedings read and review findings of fact, conclusions of law and complex appeal decisions; and research state and federal laws, including case law, regulations and policies. Positions evaluate Medicaid Cost Settlement Agent's reasoning in applying the laws, regulations, policies and cases to the facts; assign appeal cases, track appeal proceedings and mediate initial reimbursement differences between providers and the Department of Medical Assistance Services. Positions related to the auditing of financial records develop and implement health care audit training; make formal presentations and occasionally conduct workshops regarding Medicaid reimbursement to health care institutions. Positions make formal presentations; occasionally conduct workshops regarding Medicaid reimbursement to health care institutions; establish internal program controls to insure the accuracy and uniformity of issues relating to reimbursement, appeals involving extremely large amounts of money; and monitor audit or appeal progress in relation to overall program objectives. Positions in this class may hire certified public accountants on contract to complete ad hoc assignments.

Supervision Given: Provides general direction to Medicaid Reimbursement Audit Supervisors, their subordinate staff or Medicaid Cost Settlement Agents.

Supervision Received: Administrative direction is received from the Medicaid Director of Cost Settlement and Audit. Completed work is judged in terms of accomplishing reimbursement auditing or institutional health care appeal program objectives.

Scope: Responsibility exists for program and management development of major organizational functions related to reimbursement audits or appeals process. Decisions affect financial management, the institutional appeal process and timely reimbursement of nursing homes, hospitals and other institutional providers of health care.

Impact of Actions: Decisions affect the uniform application of statewide financing for the medically indigent to receive institutional health care or timely appeal decisions concerning institutional health care providers. Effective management of program results in positive relations between health care organizations, Medicaid program and patients, and ensures the proper use of financial resources.

Personal Contacts: Frequent internal and external contact with Health Care Financial Administration (HFCA) officials, health care association officials, health care provider representatives such as attorneys and certified public accountants, institutional providers and with the Attorney General's office regarding programmatic audit issues, appeal processes, reimbursement and payment and the provision of assistance on the reimbursement appeal process.

Knowledge: Comprehensive knowledge of federal and state laws and regulations affecting institutional health care financing or appeals; of principles and technical methods of professional auditing or finance, accounting and applied research; and reimbursement accounting and financial analysis of health care institutions and chain organizations. Considerable knowledge of Health Care Financial Administration (HCFA) policies and practices in financing institutional health care, Administrative Process Act, applicable state and federal laws, regulations and policies relating to institutional reimbursement and appeals; of institutional health care, and of institutional health care provider accounting practices.

Skills: None identified for this class.

Abilities: Demonstrated ability to design an audit program, audit program training and program controls; to maintain a uniform reimbursement system for institutional health care services; to interpret complex statutes and regulations, HCFA guidelines, Generally Accepted Accounting Principles, Generally Accepted Auditing Standards, professional audit accounting guides and reimbursement principles; to analyze and prepare written summaries and reports on complex accounting issues; to prepare legislative or regulatory initiatives or amendments; to conduct formal presentations; and to direct and motivate a professional auditing or appeal program staff.

QUALIFICATIONS GUIDE*

Licenses or Certification: None.

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

Level and Type of Experience: Experience in supervising an auditing, legal, or accounting program.

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 April 1990.