Serves as a designated lead worker over lower level staff which must include a technical MAS 3; or provides formal provider training to ensure uniform application of program policy; or interprets policy/regulations, analyzes workflow and automated systems problems, devises and implements new and revised procedures and monitors ongoing systems operations in the broader aspects of Medicaid Management Information System (MMIS) related activities.

Plans payment of billings from medical practitioners and hospitals for medical care recipient;  

Creates billing instruction for providers; 

Assists lower-level supervisors and specialists in determining final disposition of complex billings; instructs employees in use of tact and diplomacy;  

Consults with unit head and supervisor on policies and procedures, problem solving, work flows, public relations and related matters; 

Meets with medical providers to resolve problems and with medical staff on development of program policy;  

Provides external training for providers; 

Monitors the ongoing activity of certain providers and recipients that have been identified as deviating from pre-described norms of practice;  

Correlates input obtained from outside sources into case files to begin building history on specific providers;  

Aids in the development and implementation of medical policy and pricing controls in the Medicaid Management Information System;  

Uses Medicaid Management Systems generated production and control reports to maintain a smooth work flow and ensure that claims are processed in an expeditious and accurate manner;  

Identifies instances of provider or recipient over-utilization and refers them to the appropriate agency for review;  

Identifies systems and workflow problems; 

Performs other work as required.

Knowledge of:  medical care rules and regulations; medical terminology, anatomy and pharmaceuticals; principles of employee development, effective supervision and public relations.  

Ability to:  plan, supervise and direct organization composed of related units; make valid decisions on complex medical billings, inquiries and policy matters; use tact and diplomacy in handling correspondence or in direct contacts; establish and maintain effective relationships with physicians, hospitals and other authorized vendors; conduct staff meetings; train and instruct others in procedures.

There may be instances where individual positions must have additional licenses or certification. It is the employer’s responsibility to ensure the appropriate licenses/certifications are obtained for each position.

A Bachelor's degree

AND

two years of experience providing direct client services or counseling of customers in the areas of health insurance, disability, or other related health benefits; public assistance eligibility determination; health insurance premiums/claims processing,  adjusting, and  investigation; or other medical premiums/claims related experience.

OR 

One year as a Medical Assistance Specialist 3.  

Experience providing direct client services or counseling of customers in the areas of health insurance, disability, or other related health benefits; public assistance eligibility determination; health insurance premiums/claims processing,  adjusting, and  investigation; or other medical premiums/claims related experience will substitute, year for year, for the required education.