UTILIZATION REVIEW ANALYST SENIOR 41032

8/16/90 B

This is the second 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 independently plan, develop and coordinate Medicaid sponsored service programs and projects with other agencies to ensure that specialty program goals and objectives are met, service delivery is promoted and standards and procedure guidelines for health care providers are developed. Positions also independently analyze and resolve specialty claims on hospital lengths of stay that require justification of medical necessity. Specialty programs or activities include Ventilator Dependent, Expanded Prenatal Services, Early and Periodic Screening, Diagnosis and Treatment, specialized waivers and hospital utilization review. This class is distinguished from the Utilization Review Analyst by its responsibility for a single Medicaid specialty program or program activity coordination or by the level of review knowledge of medical issues and documentation found in acute care.

Complexity of Work: Performs work of moderate difficulty in coordinating special Medicaid programs by independently planning, developing, initiating, and evaluating services provided through multiple agencies or by analyzing Medicaid and State and Local Hospitalization acute care hospital claims which are not medically justifiable to determine medical necessity and to approve or deny the payment of the claim. Researches availability and utilization of program standards and provider qualification requirements by reviewing the scope of practice, professional literature and information from states providing similar programs. Identifies problems affecting program growth. Recommends to management necessary changes in program requirements to ensure quality and quantity of services provided. Develops and implements statewide quality assurance surveys for data collection from recipients of services to evaluate quality of services, recipient satisfaction with services and areas of improvement. Conducts on-site visits to providers to review program records, identify appropriateness of specialty services provided to Medicaid recipients and compliance with established state and federal regulations, and to provide technical assistance, consultation and training in program areas. Conducts on-site reviews in hospitals to monitor and evaluate hospital utilization review plans and utilization review meetings to determine compliance with state and federal regulations. Reviews and evaluates in-house patient charts on Medicaid and State and Local Hospitalization recipients to determine if severity of illness and intensity of service criteria were met in relation to acute care provided. Evaluates hospital admissions documentation and other data to ensure that required documentation is included in patient records. Makes recommendations for corrective action to be taken by hospital on basis of on-site review. May determine the statistics for the rate at which claims are not paid on-line through the Medicaid Management Information System; maintain statistical data on second surgical opinions with days of hospital stay approved and days denied and maintain the records of the total for cost avoidance; determine hospitals having a frequency of non-compliance with state and federal utilization review guidelines and the continuity of health care delivery and potential fraud and abuse cases to be referred for investigation; provide training to hospital quality assurance coordinators, practioners and others on quality assurance practices such as periodic patient case review and documentation of findings; consult with medical consultants in the review of denials for appeals of hospital lengths of stay attributable to a specific medical condition to assure that full consideration was given to denial of the claim; research and respond in writing to policy and procedure inquiries from other state and federal agencies and provide program service information for federal and state reporting and validation requirements; and may testify in informal hearings and appeals regarding adverse program decisions on hospital lengths of stay.

Supervision Given: Supervision is typically not a factor.

Supervision Received: Receives general direction from a Medical Assistance Services Supervisor or Medical Facilities Assistant Director who reviews research and analysis findings and recommendations related to meeting program objectives.

Scope: Positions in this class affect the continuation of a specialty Medicaid Program or program activity impacting on specifically targeted indigent populations having unique needs and higher health care costs and affect payment of claims related to medical necessity for hospital length of stay and the compliance of hospitals with state and federal guidelines for utilization review.

Impact of Actions: Effective completion of assigned agency program specialties can result in cost savings to the Medicaid Program as specific health care needs of the specialty program target population are addressed in a more efficient and prompt manner. Decisions on hospital utilization review have a significant impact on the compliance of hospitals with state and federal regulations and on the implementation of corrective actions by hospitals. Errors in judgement could result in discontinuation of program services poor participation by other agencies, non-detection of hospital fraud and abuse activities, loss of funds to the agency, non-compliance by hospitals with state and federal regulations, federal and state audits of the agency, excessive appeals by physicians and adverse relations with providers and recipients.

Personal Contacts: Frequent internal and external contacts with recipients, health care providers, other state and federal agencies, private community resources, and other sections within the agency to provide and obtain information such as budget statistical data, systems data on services, program policy and procedure, specialty program issues, resolve the utilization review process and on the coordination of services.

Knowledge: Considerable knowledge of the health and social service needs of the elderly, mentally retarded, mentally ill, high risk pregnant women and adults and children with special health care needs; medical standards of treatment; hospital utilization review process; health care and social service delivery systems; federal and state health care and social services regulations;' and medical terminology; working knowledge of community resources and volunteer agencies; negotiation techniques; presentation techniques; project management; and information systems and sampling techniques.

Skills: Working skill in keyboarding.

Abilities: Demonstrated abilities to analyze data and resolve problems; research and identify changes in program requirements and policies; communicate effectively orally and in writing; interpret state and federal regulations; organize and prioritize work assignments; use independent judgement to make decisions; manage special projects, draft budget amendments; prepare feasibility reports; conduct and guide meetings; make presentations to groups of varying size and diversity; and to work independently with a minimum of supervision with a variety of governmental agencies and health care providers.

QUALIFICATIONS GUIDE*

Licenses or Certification: None.

Education or Training: Graduation from an accredited college or university with course work in nursing or medicine.

Level and Type of Experience: Experience in coordinating and planning health care program specialties or program activities and in analyzing medical records to determine medical necessity for health care services.

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.