06/24/1991 39670

THIRD PARTY LIABILITY TECHNICIAN SUPERVISOR

DEFINITION:

This is technical supervisory and administrative work in the collection, review and analysis of medical assistance claims and other information used to identify and resolve third party liability for medical assistance program service related claims that should be paid by Medicare, private insurers, or other resources.

Employees in this class supervise and direct TPL Program Technicians and clerical support staff engaged in the review and analysis of claims submitted by medical assistance program service providers in order to identify claims that are liable for payment by Medicare, legally responsible relatives or commercial health care insurers. Work involves the responsibility for the accuracy, completeness and timeliness of medical assistance claims, as they pertain to Third Party Liability cost recovery activities, review and resolution, directing special projects and group recoveries, working with staff in county domestic relations sections, Social Security Administration offices and various DPW offices to obtain medical assistance claims information, monitoring work flow and implementing new procedures as needed, providing staff training, conducting conferences and staff meetings, and preparing reports or responses to inquiries concerning regulations, operational methods and administrative procedures. Work also includes the resolution of complex and sensitive issues by conducting independent research and conferring with applicable officials. Work requires the application of independent judgment in accordance to the policies and procedures of the Third party Liability program . Work is preformed under the general direction of a program manager and is reviewed through reports and conferences for conformance to established policies and procedures and though results achieved in meeting goals and objectives.

EXAMPLES OF WORK:

Supervises TPL Technicians and participates in investigating medical assistance On Line Pending Resolution System claims by collecting and analyzing information on individual claims, and identifying if Medicare, legally responsible relatives or a commercial health care insurer is liable for the payment of medical assistance program services provided to eligible clients.

Coordinates program activities with other departmental offices and state agencies, county assistance offices, county courts, commercial health care insurers, domestic relations sections, and the Social Security Administration.

Directs Technicians in the interpretation and application of federal and state mandates, policies and procedures governing the third party liability program.

Supervises clerical staff who provide support in the logging, input and processing of data applicable to the third party liability program.

Distributes and monitors work assignments to assure effective utilization of staff and to maintain accuracy and production; adapts work flow to accommodate critical or priority situations, special projects, and peak work periods; directs special projects and group recoveries; and works with county domestic relations offices to obtain medical assistance claims information.

Evaluates unit activity reports and reviews subordinate work products for completeness, accuracy and timeliness of claim research and resolution; and assures the timely updating of data into the automated files.

Provides technical assistance to Technicians and resolves complex and sensitive issues.

Directs and participates in the preparation of correspondence and reports in response to inquires from medical assistance program service providers and other state and federal agencies concerning the TPL identification and recovery program; prepares reports identifying actual and potential claims processing problems.

Provides staff training in techniques, policies and procedures and provides guidance to subordinates on special projects and new assignments.

Evaluates staff performance, makes recommendations regarding personnel actions, and prepares employee performance evaluation reports.

Receives grievances and complaints by subordinates, conducts initial investigation into the causes and conditions, discuses with employee and resolves or recommends resolution to the grievance to complaint.

Reviews compiled data and prepares reports of unit activities.

Performs related work as required.

REQUIRED KNOWLEDGES, SKILLS, AND ABILITIES:

Knowledge of federal and state regulations, policies, procedures and rules relating to the various aspects of medical assistance program operations and services, the third party liability program, state insurance laws, Workman's Compensation laws, and Health Care Finance Administration requirements.

Knowledge of the procedures of identifying, analyzing and resolving payment claims submitted by health care service providers for which Medicare or private insures are liable.

Knowledge of Third Party Liability claims resources, the accessibility of data from the TPL and MAMIS automated system files, and the manual sections of the Medical Assistance regulations pertaining to billing and provider agreements.

Knowledge of the principles and practices of supervision.

Ability to plan, direct and coordinate the work of subordinate staff conducting reviews and identifying third party liability for payment of medical assistance claims.

Ability to apply the basic principles and techniques of supervision.

Ability to identify, interpret and apply third party liability policies, procedures and regulations.

Ability to establish and maintain effective and cooperative working relationships with staff and with other governmental and private agencies.

Ability to make clear and pertinent statements orally and in writing.

MINIMUM EXPERIENCE AND TRAINING:

Two years of experience as a Third Party Liability Program Technician.

or

Five years of technical work in a Health Care claims processing field.

or

Any equivalent combination of experience and training.