The class incumbent is responsible for administering the conduct of fiscal and medical care audits to assure the integrity of the Medicaid Program as well as the development, revision and implementation of regional or statewide programs in compliance with State and Federal policies, procedures and regulations.
Supervises a staff of 5-10 Internal Auditor II, Medicaid Services Nursing Administrator, Medicaid Services Nurses, and Medicaid Restricted Recipient Specialists
Approximately 2,800 Medicaid providers
Approximately 62,000 individuals eligible monthly
Annual provider payments of 270 million dollars.
Nature and Scope
A class incumbent reports to a Social Services Chief Administrator and is responsible for ensuring that both recipients and providers comply with Medicaid regulations. Work includes supervising fiscal audits, assuring excessive payments are recovered and recommending and supervising corrective action/sanctions. In addition, the incumbent oversees and coordinates program policy for fiscal and medical reviews and directs staff engaged in conducting medical care necessity reviews of clients. The incumbent develops and revises statewide Medicaid policy and procedure, oversees identification of abuses of the Medicaid Program and implementation of control of utilization by recipients and providers. The incumbent administers the statewide Medicaid "Restricted Recipient" Program which provides case management of recipients determined to have abused or defrauded the Medicaid Program. The incumbent is also responsible for assuring compliance with federal regulations and State Plan requirements. The incumbent must maintain and initiate changes to a complex computerized system to generate statistical exception data which must be interpreted accurately to meet Federal and State case review selection requirements. The incumbent conducts policy and fiscal impact analysis, writes reports, executive summaries, legal documents and drafts legislation for review by Deputy Director. The incumbent represents the agency by making presentations and serving on committees. The incumbent works in conjunction with regional/state/national Medicaid Fraud Control Units, attorneys, medical professionals, professional licensing authorities, the Welfare Fraud Unit, and outside organizations.
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.
Supervises the conduct of complex medical utilization and financial audits of providers and recipients for the State's Medicaid Program.
Plans, advises, supervises, formulates work plans, assesses and evaluates methods and productivity for the unit.
Supervises and monitors the "Restricted Recipient" Program by developing policies, standards and methods for identifying abusers of Medicaid services and ensuring corrective action is taken to control utilization by recipients.
Supervises the maintenance of accounting records for recovery of overpayments for Medicaid Program statewide.
Writes/monitors/negotiates contractual agreements. Collects, analyzes, reviews, and evaluates information provided by contracted services, audit firms and professional review organizations in order to assess compliance with quality care, financial regulations and Medicaid criteria.
Develops, implements and supervises computerized systems for various components of Medicaid Program. Assesses current operations and regulation requirements for enhanced computerization.
Supervises the investigation of and responses to complaints from providers, clients, etc.
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 auditing, accounting, program analysis/ implementation, Medicaid Program policies, State and Federal laws and regulations for Medicaid.
Knowledge of business administration, computer systems, statistics, business law, and contract compliance.
Knowledge of medical terminologies, use of medical services, counseling and interviewing.
Knowledge of supervisory principles and practices.
Knowledge of research design, application and system analysis, economics, statistics, cost-benefit analysis, and management.
Knowledge of client case management.
Knowledge of principles, practices and techniques of human service work.
Skill in oral and written communication, interpersonal relations.
Skill in assessment, interpretation and application.
Ability to assess and solve problems.
Ability to collect and interpret data.
Ability to understand computer systems.
Ability to analyze situations, evaluate information and recommend courses of action.
JOB REQUIREMENTS for Medicaid Surveillance Administrator
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 making recommendations for continuation or changes to operations, programs, services, policies or procedures based on findings.
Three yeas experience in conducting studies such as evaluating operations, programs, services, policies and procedures to determine efficiency, effectiveness, whether goals and objectives are met and compliance with laws, rules, regulations, polices and procedures.
Six months experience in conducting investigations which includes conducting interviews to obtain confidential information, gathering evidence and documenting findings.
Six months experience in narrative report writing.
Knowledge of descriptive statistics such as the mean, median, mode or standard deviation.
Knowledge of managing information systems.
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.