UTILIZATION REVIEW ANALYST 41031

8/16/90 B

This is the first class in the Utilization Review series that conducts utilization review activities related to individual Medicaid program areas for quality assurance and compliance with established state and federal regulations, policies and laws. Positions in this class conduct on-site utilization reviews with providers which include complex analysis of Medicaid recipient and health care provider documentation and patient assessments for enrollment and pre-admission screening to ensure that health care services provided through Medicaid are cost effective, appropriate and within quality and level of care standards. This class is distinguished from the Utilization Review Analyst Senior by the latter's responsibility for coordinating or performing specialty Medicaid programs or activities or by the level of medical knowledge needed to perform the review.

Complexity of Work: Performs work of moderate difficulty which involves conducting on-site visits to health care providers and health care facilities to evaluate the level and quality of care, medical and social services needed by Medicaid recipients and compliance with Medicaid standards. Reviews and analyzes admissions forms, provider agency applications, provider contracts and patient care assessment documentation and prepares documentation for coding or input into the Medicaid Management Information System. Maintains records on utilization reviews which are presented during federal and state program audits. Makes recommendations to management on contract renewals, reimbursement for services rendered, adjustments in services, and policy or program changes. Identifies Medicaid recipient case management needs, long term care needs for recipients or changes in the required level of care. Prepares reports and summaries for management, physicians, attorneys, and recipients regarding disposition of patient care issues. Provides technical consultation and assistance to providers on policy and procedure application and interpretation. Conducts provider seminars on patient classification system, policies, form preparation,and other related areas. Serves as liaison with recipient support agencies to ensure the protection of recipient support agencies and the protection of recipient eligibility for return to the community from the nursing home environment. Prepares written correspondence to recipients and their families, community based care and institutional care providers, community agencies, other health care providers and other organizations on services rendered and other Medicaid issues.

Supervision Given: Supervision is typically not a factor.

Supervision Received: Receives directions from a Medical Assistance Services Supervisor in the form of general assignments and periodic evaluations of work.

Scope: Positions perform a wide range of analytical as well as health care evaluative services which affect the efficiency and integrity of Medicaid operations, recipient quality of care and provider reimbursement for services rendered.

Impact of Actions: Decisions on the extent and quality of care provided have a significant impact on recipients' health, safety and welfare and providers' compliance with established standards of care. A significant cost in time, state and federal funding, services and recipient and provider goodwill may be incurred through errors in judgement.

Personal Contacts: Frequent internal and external contact with recipients and their families, health care providers, local Departments of Health and Social Services, other human resource agencies, physicians, social workers, occupational and physical therapists, nursing home staff, community agencies and the public to provide information related to Medicaid services, other health care and social service sources of funding and reimbursement and to advise them on a variety of Medicaid and other health care procedures, programs and issues.

Knowledge: Considerable knowledge of the health and social service needs of the elderly, children, disabled, mentally ill, mentally retarded, and others with special health care needs; health and social service systems; medical terminology; instructional methods and techniques; community resources and volunteer agencies; interviewing techniques; and assessment of plans of care. Working knowledge of medical standards of treatment and in information systems principles and application.

Skills: Working skills in keyboarding.

Abilities: Demonstrated ability to work independently with a variety of governmental agencies and health care providers; to interpret federal and state regulations and policies; to communicate effectively orally and in writing, to organize, prioritize and plan workload assignments; to research and analyze data related to health care needs of recipients and quality and level of care provided; to respond to sensitive inquiries form recipients, providers and government officials; to use independent judgement in making decisions about work related issues; to direct recipients and providers in resolving problems; to conduct interviews with diverse individuals; to perform assessments of information and documentation of data; and to work within established timeframes and deadlines.

QUALIFICATIONS GUIDE*

Licenses or Certification: None.

Education or Training: Graduation from an accredited college or university with course work in social services, a medical discipline, or a related field.

Level and Type of Experience: Experience assessing, analyzing and reviewing medical and social services care data in a social services or health care program setting.

Any 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 August 16, 1990.