Medical/Social Services Consultant II

State of Delaware•Dover, DE

About The Position

Employees in this class perform federally mandated quality control reviews under the Medicaid Eligibility Quality Control (MEQC) Program to ensure accuracy and compliance with eligibility and benefits determinations. Primary work involves conducting third-party reviews of sampled statewide Medicaid and Medical Assistance cases. Employees apply in-depth knowledge of applicable program requirements, state and federal laws, rules, regulations, and quality control methods, as well as use discretion and independent judgment to perform reviews and assess eligibility accuracy. Work includes researching, compiling, and analyzing data gathered through case sampling and review; obtaining and evaluating records and supporting documents; verifying household eligibility factors and benefits calculations; identifying errors and discrepancies; and determining whether cases were correctly processed and placed in the appropriate program. Cases must be reviewed within mandated time frames. This is advanced level medical/social services consultant work, with an emphasis on consultation and oversight of medically complex case management services. In addition to work performed at the Medical/Social Services Consultant I level, employees independently perform more advanced work under minimal supervision. Employees at this level perform program and quality review work and may also assist in the evaluation and planning of existing programs to better target Social Determinants of Health factors for underserved or high-risk populations. Receives minimal supervision from a technical or administrative supervisor; the supervisor defines objectives, priorities, and deadlines and assists the employee with unusual situations. Independently provides quality assessments such as oversight and review of eligibility determination work, chart audits, and/or formal examination of service delivery obligated under regulatory entities, waivers, or contracts. Documents and prepares comprehensive reports of found deficiencies and recommends correction plans to remain in compliance. Analyzes service metrics against existing policies/ services to identify barriers to care or services, drafting recommendations for policy changes that promote wellness and equitable access to health services. Identifies trends in client needs and contributes to planning sessions on program development and the implementation of new services or protocols. Leads the planning and coordination of community facing events such as testing clinics, fairs, school outreach, programs and other group events that support population health goals, targeting positive impacts on the Social Determinants of Health (SDOH) for underserved or high-risk populations. May supervise a small staff of lower-level case workers and/or administrative support staff. Supervision includes two or more merit full-time positions. The elements of supervision include performing the following on a regular and continuing basis: planning, assigning, reviewing, evaluating, coaching, training, disciplining, and recommending hire, termination, and promotion. May serve on boards or special committees as a subject matter expert or advocate.

Requirements

Possession of a Bachelors degree or higher in Health, Behavioral or Social Science or related field.
Two years' experience in case management such as assessing, planning, developing, implementing, monitoring, and evaluating options and services to meet an individual's human service needs.
Two years' experience in making recommendations as part of a client's service plan such as clinical treatment, counseling, or determining eligibility for health or human services/benefits.
Two years' experience in client healthcare resource coordination and support.
Six months experience in interpreting laws, rules, regulations, standards, policies, and procedures.
Six months experience in narrative report writing.

Responsibilities

Manages cases over the continuum of a healthcare delivery system for clients with complex, chronic, and specialized physiological medical conditions.
Facilitates access to medical and social service resources across public, private, and community sectors.
Collaborates with health care providers, services, programs, and insurance entities to develop tailored service plans and interventions.
Integrates care and communication between stakeholders to ensure optimal health and social outcomes.
Navigates and consults on the intersection of services, authorizations, and payments between the clients, providers, insurance programs and/or Managed Care Organizations.
Works with providers and insurance entities to obtain pre-authorizations and referrals.
Schedules and attends multidisciplinary evaluations and assessments.
Facilitates and participates in discharge and transition planning.
Formally responds to casework inquiries and investigates complaints, assessing services or eligibility against legal entitlements or contracts.
Provides subject matter expertise through outreach and education to program staff, community members, providers, and other stakeholders through special community events or health education and preventative services.
Advocates for community health and wellness.
Maintains and tracks service, eligibility, and referral data sets, manages data for reporting and program planning.
Coordinates and allocates funding sources for special program eligibility.
May support emergency preparedness and response efforts during pandemics or natural disasters, and/or intervene in facilitating care for clients in health crisis.
May provide home visits, and/or virtual appointments.
Performs other related duties as required.
Provides quality assessments such as oversight and review of eligibility determination work, chart audits, and/or formal examination of service delivery obligated under regulatory entities, waivers, or contracts.
Documents and prepares comprehensive reports of found deficiencies and recommends correction plans to remain in compliance.
Analyzes service metrics against existing policies/ services to identify barriers to care or services, drafting recommendations for policy changes that promote wellness and equitable access to health services.
Identifies trends in client needs and contributes to planning sessions on program development and the implementation of new services or protocols.
Leads the planning and coordination of community facing events such as testing clinics, fairs, school outreach, programs and other group events that support population health goals, targeting positive impacts on the Social Determinants of Health (SDOH) for underserved or high-risk populations.
May supervise a small staff of lower-level case workers and/or administrative support staff.
May serve on boards or special committees as a subject matter expert or advocate.