A class incumbent administers the Durable Medical Equipment and other services program for the state Medicaid program.
Nature and Scope
The class incumbent reports to an administrative superior and is responsible for reviewing requests for authorization of specific medical services such as durable medical equipment/ supplies and other medical services ie: vision and hospice care. Work is normally performed in accordance with established state and federal program guidelines when authorizing routine requests. However when there are authorization requests that do not appear to meet medical necessity requirements, the incumbent must contact physicians and other medical service providers including: equipment manufacturers, and/or in-house medical staff to request clarification of client medical condition, and/or medical necessity of requested equipment before authorizing payment. An incumbent is responsible for developing guidelines relating to services/ equipment covered by the program and procedures for submitting claims. This includes updating covered equipment/supplies, establishing/revising billing codes and writing procedures manual for use by providers and billing agent. In addition, the incumbent participates with other administrative staff in conducting program analysis, responding to requests for information from service providers, government officials and other agencies. The incumbent resolves provider and client problems with the provision of program services.
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.
Reviews Medicaid policies and procedures with service providers and explains billing procedures.
Authorizes approval for reimbursements for new equipment based on review of previous approval for similar equipment, and in accordance with Medicaid guidelines.
Conducts training to service providers and medical personnel regarding covered equipment, billing and coding procedures.
Reviews claims submitted by service providers to ensure information is valid and in compliance with regulations.
Confers with other administrative staff, medical consultants, and community representatives as necessary to resolve policy and payment issues.
Initiates and develops guidelines/policies for various Medicaid services and recommends program changes.
Participates with other administrative staff in conducting program analysis and responding to requests for information from providers, government officials and other agencies.
Revises procedure and coding manuals for use by providers.
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 state and federal laws, rules and regulations as they relate to the Medicaid Program.
Knowledge of medical terminology.
Knowledge of applicable Department policies and procedures.
Ability to explain Medicaid policies and procedures.
Ability to evaluate situations and make appropriate recommendations.
Ability to establish and maintain effective working relationships with co-workers and providers.
JOB REQUIREMENTS for Medicaid Services Specialist
Applicants must have education, training and/or experience demonstrating competence in each of the following areas:
Six months experience in benefits claims processing such as health, dental, or life.
Six Months experience in using an automated information system to enter, update, modify, delete, retrieve/inquire and report on data.
Six months experience in interpreting Medicaid laws, rules, regulations, standards, policies and procedures.
Six months experience in narrative report writing.