JOB TITLE: DIRECTOR, BUREAU OF FEE-FOR-SERVICE PROGRAMS, OMAP

JOB CODE: 39590

DEFINITION: This is highly responsible administrative work directing the planning, program management, and evaluation of the Medical Assistance (MA) fee-for-service program in the Office of Medical Assistance Programs (OMAP) in the Department of Human Services (DHS).

The employee in this job plans, organizes, directs, coordinates, and evaluates the statewide operations of OMAP’s MA fee-for-service (FFS) program. Work involves developing policies to ensure the efficacy and effectiveness of MA FFS operations; modifying regulations for administering hospital and outpatient programs; ensuring MA FFS provider compliance with federal and state legislation and court decisions; overseeing enrollment, prior authorization, outreach, and training functions for MA FFS; and reviewing, analyzing, and evaluating MA FFS programs to coordinate the development of procedural and program changes to medical reviews and other special program operations. The employee in this job plans, organizes, and directs outreach activities to assess MA FFS program needs and evaluate current operations for the purpose of improving MA consumer and FFS provider services; provides direction on the expansion of the managed health care system; monitors and evaluates the need for the provision of inpatient and outpatient medical services; and oversees the medical review of all MA FFS provider services for appropriateness and compliance. Supervision is exercised over professional, technical, and clerical staff; and work is reviewed by the OMAP Deputy Secretary through conferences, reports, and evaluation of program effectiveness.

EXAMPLES OF WORK: (NOTE: The examples of work are representative of the work, but every position classified to this job may not perform all examples of work listed. Conversely, this is not an all-inclusive list of work examples.)

• Reviews federal and state program plans and legislation affecting the MA FFS program, and develops and implements appropriate revisions in policies and procedures and program goals and objectives.

• Oversees the development, implementation, and operation of Medicaid FFS funded inpatient and outpatient services.

• Oversees the medical reviews of hospital inpatient admissions, short procedure units, home health, durable medical equipment, outpatient drug, and ambulatory surgical centers under the MA FFS program.

• Oversees MA FFS provider enrollment, prior authorization of MA FFS services, and response to inquiries from MA consumers and FFS providers.

• Screens procedures for the rejection or enrollment of interested MA FFS provider applicants and the enrollment activities for participation as approved providers.

• Directs statewide programs providing services to MA FFS consumers with special medical needs.

• Ensures federal and state requirements are met by adopting standards, protocols, and medical review procedures to safeguard against unnecessary medical procedures and to promote proper utilization of inpatient and outpatient services.

• Researches and develops program initiatives designed to maximize federal funding with minimal state financial exposure and planning.

• Directs the service centers for enrolled MA FFS providers, which offer guidance on billing policies and procedures related to reporting and submitting invoices for payment for services delivered.

• Oversees the service center responding to questions from recipients in the FFS program regarding billing issues, provider inquiries, or coverage issues.

• Provides supervision and assistance to the intense medical case management of nurses providing care management, assessment, and ongoing follow-up to ensure delivery of health care and social services.

• Oversees the pharmacy call center, the development and maintenance of the drug reference file and the preferred drug list, the supplemental and federal drug rebate programs, and the administration of the specialty pharmacy drug program.

• Provides guidance and technical assistance for inquiries requiring interpretation or clarification of MA FFS or DHS policies.

• Performs the full range of supervisory duties.

• The employee in this job may participate in the performance of subordinates’ work consistent with operational or organizational requirements.

• Performs related work as required.

ENTRY LEVEL KNOWLEDGES, SKILLS, AND ABILITIES:

• Knowledge of the laws, regulations, and policies governing MA programs and services.

• Knowledge of the principles and methods of policy and program planning, development, and evaluation.

• Knowledge of the principles and practices of employee supervision.

• Knowledge of the use and functionality of Microsoft Office Suite software.

• Ability to think critically and solve program problems.

• Ability to analyze and interpret written and numerical information.

• Ability to analyze and interpret policies, procedures, and regulations.

• Ability to establish and maintain effective working relationships.

• Ability to communicate effectively orally.

• Ability to communicate effectively in writing.

MINIMUM EXPERIENCE AND TRAINING: (NOTE: Based on the Entry Level Knowledges, Skills, and Abilities)

• Six years of professional experience in medical assistance, health care insurance, or health care services including three years of supervisory experience, and a bachelor's degree;

or

• An equivalent combination of experience and training which includes three years of professional supervisory experience in medical assistance, health care insurance, or health care services.