08/07/1996 49240

HIPP OPERATIONS SPECIALIST SUPERVISOR

DEFINITION: This is technical and supervisory work determining the cost effectiveness of alternative health care programs for eligible medical assistance recipients under the Department of Public Welfare's Health Insurance Premium Payment (HIPP) Program.

Employees in this class supervise and direct HIPP Operations Specialists and clerical support staff engaged in determining the cost effectiveness of Employer Group Health Programs(EGHP) and Medicare Supplement A/(Medigap) Insurance applications, enrolling eligible Medical Assistance recipients into employer group health insurance plans, and for the purchase, administration, and maintenance of the Department's Medigap Program for cost effective, dually eligible Medicare/Medicaid recipients. Work involves negotiating with employers, unions, and/or insurance carriers on behalf of clients to resolve issues, establishing premium payment methodology, enrollment dates and policy changes; educating employers, insurance carriers, county assistance office (CAO) workers, medical providers and other interested parties regarding the HIPP Program, federal laws mandating the programs and their participation. Work involves assigning work to subordinate staff, monitoring work flow, providing training and technical guidance, implementing new work procedures, conducting conferences and staff meetings, preparing reports, responding to inquiries concerning unit activities, approving/disapproving leave requests, and evaluating staff performance. Work includes responsibility for assuring the accurate and timely evaluation of HIPP applications, resolving complex situations by independently researching policies, laws and interpretations which govern the HIPP Program and conferring with applicable officials. The employees identify insurance providers who refuse to cooperate and determine if a case should be referred to the Department's Office of Legal Counsel for resolution. Work is performed under the general direction of the HIPP Program Manager and is reviewed through weekly reports and conferences for conformance to established policies and procedures and through results achieved in meeting goals and objectives.

EXAMPLES OF WORK: Supervises HIPP Operations Specialists and participates in evaluating applications and enrolling eligible Medical Assistance clients in EGHPs and Medigap programs.

Directs HIPP Operations Specialists in the interpretation and application of federal and state mandates, policies, and procedures governing the HIPP Program, including state insurance laws. Informs staff of relevant changes and seeks clarification as necessary.

Supervises staff in the logging, input, and processing of data applicable to the HIPP 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.

Evaluates unit activity records, compiles reports and reviews subordinate work products for completeness, accuracy and timeliness of EGHP and Medigap application evaluation and processing; responds to inquiries; and assures the timely updating of data into the automated files.

Provides guidance and technical assistance to HIPP Operations Specialists and resolves complex and sensitive issues.

Consults with and coordinates program activities with other Departmental offices, state agencies, commercial health care and insurance companies, Department of Public Welfare contracted managed health care plans, attorneys, county assistance offices, domestic relations offices, and the Social Security Administration.

Provides staff training in the techniques of application evaluation, negotiation and the settlement of effective dates, preexisting medical clauses, addition of legally supportable dependents and premium payment schedules; 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 causes and conditions and resolves or recommends resolution to the grievance or complaint.

Directs and participates in the preparation of correspondence and reports in response to inquiries concerning the function and operations of the HIPP Program, determination of eligibility, and enrollment activities.

Employees in this class may participate in the performance of their subordinates work consistent with operational or organizational requirements.

Performs related work as required.

REQUIRED KNOWLEDGES, SKILLS, AND ABILITIES: Knowledge of Federal and state rules, regulations, policies, and procedures relating to the various aspects of The Medical Assistance Program, HIPP Program, state insurance laws, and the requirements of the Health Care Financing Administration (HCFA).

Knowledge of the methods, processes and procedures for eligibility determination and negotiating policies and premium payments for Medical Assistance recipients with employers, unions, and insurance carriers.

Knowledge of the provisions, health care eligibility criteria, and the billing and provider agreements relating to Medicare, Blue Cross and Blue Shield groups, Department of Public Welfare contracted managed health care plans and commercial insurance.

Knowledge of the civil court litigation process pertaining to legal settlements and the provisions subrogation activities.

Knowledge of medical terminology, sufficient to read and comprehend medical reports.

Knowledge of resources for researching and obtaining information for case documentation, such as the MAMIS and TPL automated system files, health care providers, and insurance companies.

Knowledge of the principles and practices of supervision.

Ability to plan, organize, direct, and coordinate the work of others involved in evaluating applications and the purchase of employer group health plans and Medigap policies.

Ability to apply the basic principles and techniques of supervision, such as assignment, review, and evaluation of the work of subordinates.

Ability to identify, interpret, and apply EGHP and Medigap 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 organize, analyze, and evaluate facts, and litigation actions; draw sound technical conclusions, and make recommendations on required actions.

Ability to effectively communicate orally and in writing.

MINIMUM EXPERIENCE AND TRAINING: Two years of experience as a HIPP Operations Specialist;

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Six years of technical experience in the identification and resolution of third party liability health care claims, analysis of employer group health care plan benefits or determination of eligibility for health care insurance or medical assistance programs.

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Any equivalent combination of experience and training.