06/02/1994 70164

WORKERS' COMPENSATION MEDICAL COST CONTAINMENT CHIEF

DEFINITION: This is responsible professional administrative work at the Division level directing a state-wide program to control and manage medical costs and the provision of medical treatment to Workers' Compensation claimants.

The employee in this class plans, develops, directs, and coordinates a state-wide certification and review program to insure that medical treatment resulting from workers' compensation claims is reasonable and necessary. Directs the development and maintenance of certification criteria for Utilization Review Organizations (URO's) and Peer Review Organizations (PRO's) to qualify for reviewing the reasonableness and necessity of medical treatment. Directs thedevelopment and maintenance of administrative procedures for reviewing and certifying applicant URO's and PRO's. Directs the development and maintenance of a hearing process for rejected certification requests and for revocations of certifications for URO's and PRO's. Directs the development and maintenance of a program to investigate and to monitor certified URO's and PRO's for compliance with certification criteria. The employe in this class is responsible for taking appropriate steps when necessary to resolve difficult certification issues and to develop plans for resolving non-compliance problems which might precipitate an action to revoke a certification or terminate participation as a URO or PRO. Work involves directing the development of a fee schedule for the proper reimbursement amounts for medical treatments and procedures, directing the development and maintenance of a process to hear appeals for disputed medical fee disputes and directing the development and administering a system to resolve medical fee disputes. Work also involves an extensive level of contact with other divisions in the Bureau of Workers' Compensation, with other Bureau's in the Department of Labor & Industry, with legislators, labor union representatives, medical service providers including hospitals and other health care facilities, doctors and other medically related service providers and their representatives, insurers and self-insured employers. Supervision is exercised through subordinate managers who in turn direct the work of supervisory staff. Work is assigned by the Director of Workers' Compensation in the form of program goals and objectives and is carried out with considerable independence. Work is reviewed through conferences, reports and the establishment and review of performance objectives.

EXAMPLES OF WORK: Plans, develops, directs, and coordinates a state-wide certification and review program to insure that medical treatment provided to workers' compensation claimants is reasonable and necessary.

Directs the establishment, implementation, review, revision and publication of certification criteria for Utilization Review Organizations (URO's) and for Peer Review Organizations (PRO's).

Direct the development and maintenance of administrative procedures for reviewing and certifying applicant URO's and PRO's.

Direct the development and maintenance of a hearing process for rejected certification requests and for revocations of certifications for URO's and PRO's.

Direct the development and maintenance of a program to investigate and to monitor certified URO's and PRO's for compliance with certification criteria.

Directs the development of a fee schedule for the proper reimbursement amounts for medical treatments and procedures rendered to Workers' Compensation claimants.

Directs the development and maintenance of a process to hear appeals for disputed medical fee review findings.

Directs the development and administers a system to resolve medical fee disputes.

Directs the application of Federal Safe-Harbor regulations for allegations of unlawful self-referrals by medical service providers.

Directs the development of Bureau policies and forms related to employer lists of designated health care providers.

Maintains effective working relationships with other divisions in the Bureau of Workers' Compensation, with other Bureau's in the Department of Labor & Industry, with legislators, labor union representatives, medical service providers including hospitals and other health care facilities, doctors and other medically related service providers and their representatives, insurers and self-insurers.

Performs related duties as required.

REQUIRED KNOWLEDGES, SKILLS, AND ABILITIES: Knowledge of the Medical Cost Containment provisions of the Workers' Compensation Act.

Knowledge of the interrelationship of Medical Cost Containment to the overall processing of Workers' Compensation claims including the litigation of claims.

Knowledge of Medicare policies and reimbursement procedures applied to the processing of Workers' Compensation claims.

Knowledge of the principles and practices of public administration.

Knowledge of the principles and practices of effective supervision.

Knowledge of medical procedures and protocols sufficient to carry out the Medical Cost Containment provisions of the Workers' Compensation Act.

Ability to plan and direct the work of a professional, technical and clerical staff engaged in a statewide certification process which encompasses the writing of standards and regulations.

Ability to integrate the certification and review of URO's and PRO's into the overall function of the Bureau of Workers' Compensation.

Ability to plan and direct a statewide program investigating and monitoring certified URO's and PRO's for compliance with certification criteria.

Ability to direct the development of fee schedules for the proper payment of medical treatment provided to Workers' Compensation claimants.

Ability to direct a system for the resolution of medical fee disputes.

Ability to direct an appeal process for disputed medical fee resolutions.

Ability to provide advice, consultation and leadership in relation to issues that arise in the certification or decertification of URO's and PRO's, or in the determination of medical fee disputes.

Ability to analyze and interpret rules, regulations and the law pertaining to the certification of URO's and PRO's, or in the determination of medical fee disputes.

Ability to establish and maintain effective working relationships with subordinates, associates, medical service organizations, medical service providers and their representatives, insurers and self-insurers.

Ability to write or orally present technical reports which summarize, explain, or promote the program needs or achievements of the division.

MINIMUM EXPERIENCE AND TRAINING: Four years of professional experience in the field of workers' compensation, or medical cost containment, including or supplemented by two years of supervisory experience, and a bachelor's degree. Education beyond the Bachelor's level may be substituted for the general experience on a year for year basis up to a maximum of two years.

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Any equivalent combination of experience and training that included or was supplemented by two years of supervisory experience.