A class incumbent is responsible for overseeing a reimbursement and recovery system for the Medicaid program.
Nature and Scope
A class incumbent reports to an administrative superior and is responsible for directing and coordinating the Medicaid Reimbursement program. An incumbent is responsible for monitoring contractual audit functions in order to ensure compliance with federal regulations and to recommend changes which are most cost effective and administratively efficient. An incumbent is also responsible for evaluating financial requirements and the impact of policies and legislation on the activities of Medicaid program providers and contractors. An incumbent develops corrective action plans in response to Federal reviews. Work includes developing guidelines and criteria for provider audits which delineate program needs and expectations, interpreting regulatory requirements and determining courses of action and developing and overseeing implementation of guidelines. An incumbent acts as Medicaid representative with contracted agencies and assists providers with any cost reporting, billing or program policies. In addition, the incumbent is responsible for implementing recommendations related to changes in provider reimbursement methodologies and audit/cost reporting issues.
Essential functions are fundamental, core functions common to all positions in the class series and are not intended to be an exhaustive list of all job duties for any one position in the class. Since class specifications are descriptive and not restrictive, incumbents can complete job duties of similar kind not specifically listed here.
Evaluates financial requirements and the impact of policies and legislation on the Medicaid program provider and contractor activities. Interprets reimbursement policies to ensure compliance with federal regulatory requirements. Recommends and develops reimbursement procedures to meet new or existing legislative requirements or to improve overall program efficiency.
Examines existing State agency and intermediary cost and reimbursement systems, identifies problem areas and recommends modifications to correct system deficiencies.
Performs short and long-range studies concerned with the development, application, and appraisal of reimbursement for services provided by hospitals, long-term facilities, home health agencies, and all other program providers.
Provides assistance to providers and contractors regarding provider reimbursement, financial review problems, and Medicaid recoveries. Reviews cost reports submitted by providers and oversees corrective action. Obtains and analyzes information on reimbursement and recovery systems and evaluates the applicability and impact of any changes to the Medicaid program.
Participates in the review and recommends approval/disapproval of Medicaid State Plan segments pertaining to provider reimbursement.
Evaluates overpayment recovery procedures and initiates effective recovery efforts. Evaluates contractor documentation of audits and development of overpayment as appropriate.
Provides technical and factual case information to Department of Justice, Health and Social Services, and HCFA as required.
Supervises the work of subordinate staff.
Prepares clear, complete, and concise records, reports, summaries, analysis, evaluations, and recommendations; Develops and evaluates statistical data.
Knowledge, Skills and Abilities
The intent of the listed knowledge, skills and abilities is to give a general indication of the core requirements for all positions in the class series; therefore, the KSA’s listed are not exhaustive or necessarily inclusive of the requirements of every position in the class.
Knowledge of accounting, auditing, and statistical principles and practices.
Knowledge of Medicaid/Medicare regulations, policies, and laws as well as those pertaining to HCFA programs.
Skill in the application and interpretation of Medicaid/Medicare provider reimbursement policies and procedures.
Skill in handling sensitive negotiations and meetings with attorneys, accountants, contractors, providers, and other State agencies.
Skill in the analysis of reimbursement and recovery systems.
Skill in statistical analysis.
Skill in program analysis and evaluation design.
Ability to present findings and recommendations in written or oral form.
Ability to plan, assign, and review the work of subordinates and direct a staff towards program/goal accomplishment.
JOB REQUIREMENTS for Medicaid Reimbursement Specialist
Applicants must have education, training and/or experience demonstrating competence in each of the following areas:
Three years experience in health care reimbursement which includes reviewing and categorizing claims for proper billing, analyzing cost reports, examining cost containment, and interpreting and analyzing laws, rules, regulations, policies, procedures and standards affecting reimbursement and recovery.
Three years experience in compiling, analyzing and interpreting financial data to ensure effective and efficient accounting of funds or to make projections for financial planning.
Six months experience in inferential statistics such as correlation, t-tests, f-tests or analysis of variance.
Six months experience in narrative report writing.
Knowledge of staff supervision acquired through course work, academic training, training provided through an employer, or performing as a lead worker overseeing the work of others; OR supervising staff which may include planning, assigning, reviewing, and evaluating the work of others; OR supervising through subordinate supervisors a group of professional, technical, and clerical employees.