Job Code Pay Scale Group Pay Scale Type Bargaining Unit Civil Service or Non-Civil Service Last Executive Board Change Executive Board Change History
39640 05 ST A4 C 595-11 08/07/1996
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01/01/1984 39640


DEFINITION: This is technical and administrative work involving a variety of staff assignments in support of medical assistance program services.

Employees in this class are responsible for performing technical assignments which involve the independent review, interpretation, and explanation to service providers or other interested parties of medical assistance program regulations, policies, guidelines, and administrative processes and methods. Work involves researching background information applicable to the respective type of medical assistance program service; preparing supporting documents and correspondence explaining detailed policy, procedures and administrative requirements unique for the various types of service provider groups; resolving provider claims that require technical decisions; and/or reviewing, verifying and recommending disposition of service provider enrollment applications and status change requests. Work includes responsibility for preparing correspondence in response to specific inquiries on medical assistance program operations, regulations, operating guidelines, billing procedures, and status of claims for payment for services delivered; answering questions on participation requirements, the enrollment process, utilization review process, fee schedules, and the claims payment process; and providing recommendations and documentation needed to support the approval or disapproval of applications for enrollment and participation in the program. Work is performed under the general direction of an administrative supervisor and is reviewed for conformance to departmental policies and program objectives through conferences and reports.

EXAMPLES OF WORK: Reviews, studies and interprets medical assistance program regulations, policies and operating guidelines; prepares written responses to inquiries explaining the administrative processes and procedures for participation in the medical assistance program, the enrollment process, utilization review process, fee schedules, and the claims and payment processes for medical assistance program service delivery.

Responds to telephone inquiries and written inquiries concerning the medical assistance program from the various types of program service providers, county assistance offices, legislators, inter and intra-departmental agencies, and interested others, by telephone or by drafting correspondence for the signature of the Bureau Director, Deputy Secretary of Secretary.

Reviews, verifies and researches service provider enrollment applications, documentation and requests for changes in status or authorized compensable service and certification and/or licensure documentation and refers to approving authority for disposition.

Explains the detailed procedures required for the various types of service providers to properly complete the different types of forms and invoices or claims adjustments for payment for service delivery.

Explains how invoices or claims adjustments are processed, manually or through MAMIS; provides instructions related to the billing/payment process, common errors, error resolution, status of invoices, and related matters.

Reviews and resolves provider claims that require technical decisions by researching, analyzing, interpreting and applying the governing regulations and policies and/or conferring with consultants or other state or Federal agencies on issues where claims resolutions are not clearly defined.

Performs related work as required.

REQUIRED KNOWLEDGES, SKILLS, AND ABILITIES: Knowledge of Federal and state rules and regulations and governing policies and procedures relating to the various types of medical assistance program operations and services.

Knowledge of the sources of available information on participating health care service providers and the methods and techniques used for explaining or clarifying policies and procedures relating to the proper application of costs and charges for authorized services provided by the different types of participating medical assistance program service providers.

Knowledge of the types of participating health care service providers, such as hospitals, clinics, pharmacies, laboratories and medical practitioners, that are enrolled and are authorized for payment for services provided for eligible clients under the program.

Ability to carry out staff assignments requiring the gathering and interpretation of background information relative to specific medical assistance program services, and to organize and present logical explanations of program operation requirements.

Ability to apply the administrative processes and procedures for formally enrolling prospective health care service providers in the medical assistance program and the methods for processing claims for payment for authorized medical services provided.

Ability to respond to telephone and mail inquiries relating to program regulations or policies, and to prepare correspondence clarifying or explaining the administrative requirements for program participation and payment authorization for health care services.

Ability to establish and maintain effective working relationships with inter and intra-departmental personnel, medical assistance service providers, county assistance offices, and others.

Ability to express ideas effectively, orally and in writing.

MINIMUM EXPERIENCE AND TRAINING: Three years of para-technical experience which involved reviewing and responding to inquiries relating to applicable services or benefits in health care insurance programs, health care services, or medical assistance program services;


Any equivalent combination of experience and training.