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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00040170 |
Description Activated On: 4/18/2024 8:51:29 AM |
Position Purpose: Describe the primary purpose of this position and how it contributes to the organization’s objectives. Example: Provides clerical and office support within the Division to ensure its operations are conducted efficiently and effectively. Responsible for 1) analysis and monitoring of financial and claims processing reports, 2) effectively utilizing data files, 3) preparation of worksheets, charts, presentations, etc., and 4) interpreting contract language and reporting requirements to determine MCO compliance. |
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Description of Duties: Describe in detail the duties and responsibilities assigned to this position. Descriptions should include the major end result of the task. Example: Types correspondence, reports, and other various documents from handwritten drafts for review and signature of the supervisor. This position receives supervision from the Section Chief, an Accountant 3. This individual performs analytical responsibilities which require a considerable degree of initiative and judgment. Individual responsibilities include analysis of managed care financial-related data reported to the Department by our Physical Health (PH) HealthChoices (HC) Program managed care contractors (MCOs). Work involves interpretation and understanding of the HC contract, various reporting requirements, analysis of adhoc data requests, and methodologies necessary to analyze, compare and trend MCO financial related data. HC MCOs operate in five zones in the Commonwealth of Pennsylvania: Southeast, Southwest Lehigh/Capital, New West and New East. Compensation is paid by the Department to MCOs for providing Medical Assistance (MA) benefits to MA recipients enrolled in their managed care plan. MCOs are responsible to medically and administratively manage their programs, and to pay their providers for medical services rendered to enrolled MA clients. Duties include the following: • Analysis of Quarterly Financial Reports. Monitoring analysis is performed on self-reported information submitted by MCOs. Incumbent is assigned responsibilities of financial monitoring of specific MCOs and/or Zones. Analysis is completed by the incumbent through the use of calculations/formulas, etc., to assess cost and utilization. Comparative and trend analysis is also performed which involves development, maintenance and/or updates of various worksheets and preparation of written results. Monitoring reviews are performed under the Section Chief’s discretion, or as directed by the Division Director. The incumbent follows-up, as directed by the Section Chief, with MCO financial personnel to resolve problems. In addition, this position also assists the Section Chief in the development and preparation of financial presentations including graphs, charts and reports. Assigned MCO financial performance is monitored, trended and compared to other contractors, and is utilized to support the Rate Section and the Department’s actuarial consultants in rate setting development and financial contract negotiations. This task requires the understanding and interpretation of financial statements to evaluate possible financial position, profitability, solvency, liquidity and operational efficiency. Monitoring is done to evaluate the overall Financial health of the MCO through various ratios and financial indicators. This responsibility requires knowledge and experience in financial statement analysis. Results of monitoring are shared through meetings with BMCO and BFM personnel. This individual participates in assigned MCO on-site monitoring visits. • Monthly Claims Processing Review. The Financial Section is responsible to monitor monthly MCO claims processing performance. Monthly claims reports are analyzed to determine compliance with the Department’s requirements for timely adjudication and reporting. Presents results to the Section Chief and to the contract manager, and may be involved in discussions of sanction amounts in the event of MCO noncompliance with the requirements. Prepares draft correspondence to MCOs as needed on deficiencies, sanctions assessed and applicability of corrective action, if determined necessary. • MCO Price and Utilization monitoring and analysis. Utilization and price data are reported quarterly by the MCOs for physician, inpatient, dental and pharmacy services provided to their enrolled MA clients. Comparisons of data are done and trended over time to determine if increases in expense are caused by increased usage or higher rates being paid to providers. Charts, graphs and reports are prepared and presented to supervisor in the effort to manage and control costs of the managed care program. • Access to Care and APR-DRG Adjustment Revenue. The HealthChoices capitation rates include components for Access to Care payments (SE only) and APR-DRG Adjustment revenue. Analyses are prepared to determine the amount of these program payments received by the MCOs and tracking to ensure that these funds are paid out by the MCOs as specified. Periodic accounting reports are to be completed as necessary. • Electronic Reporting. MCO financial reports are filed quarterly and annually, and claims processing reports are filed monthly via a web based electronic reporting system. The incumbent participates with the Section Chief to set-up monthly/quarterly/annual reporting, review report submission to ensure all reports have been received as well as assist clerical staff with review of report certification for completeness and accuracy. The incumbent will assist Section Chief with system maintenance including setting up/removing users, setting up and maintaining annual contract submission periods as well as establishing monthly/quarterly/annual reporting submission periods. The incumbent will assist Section Chief in the developing of reporting edits and troubleshooting MCO inquiries regarding report submission issues. The incumbent will participate in providing recommendations and make decisions regarding future electronic reporting enhancements. • Supports the Section Chief with the update of the Financial Reporting Requirements and the Claims Processing Reporting Requirements. The individual must be familiar with generally accepted accounting principles, statutory accounting principles, and key objectives of financial reporting applicable to the HealthChoices Program. • Must have the ability to manipulate large data files, in order to extrapolate data for purposes of financial analysis. Develops and/or maintains Access databases and builds enhanced Excel worksheets with complex formulas, links and pivot tables. • Utilizes Department’s PROMISe system applications, reports, files, data warehouse and data store for analysis purposes. • Utilizes the Department's SMART system to review MCO compliance with the contract requirements. • Performs related duties as required. |
Decision Making: Describe the types of decisions made by the incumbent of this position and the types of decisions referred to others. Identify the problems or issues that can be resolved at the level of this position, versus those that must be referred to the supervisor. Example: In response to a customer inquiry, this work involves researching the status of an activity and preparing a formal response for the supervisor’s signature. For ongoing routine monitoring of MCO, the individual will make decisions based upon established policies, procedures, standards and Division practices. For issues of uncertainty, or in new/different situations, the individual will receive guidance from the Section Chief or Division Director for a decision to be made at a higher level of management. For reporting and monitoring noncompliance such as missing and/or incomplete reports submitted by the MCO, the individual determines when to contact the plan without necessary prior approval. In cases of inaccurate reporting, the individual provides recommendations to the Section Chief to make a decision to contact the MCO. |
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Requirements Profile: Identify any specific experience or requirements, such as a licensure, registration, or certification, which may be necessary to perform the functions of the position. Position-specific requirements should be consistent with a Special Requirement or other criteria identified in the classification specification covering this position. Example: Experience using Java; Professional Engineer License Experience: Licenses, registrations, or certifications: 1. N/A 2. N/A 3. N/A 4. 5. 6. |
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Essential Functions: Provide a list of essential functions for this position. Example: Transports boxes weighing up to 60 pounds.
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