SR MEDICAL CARE SPECIALIST

State of careers Rhode Island

About The Position

GENERAL STATEMENT OF DUTIES: To be responsible for the supervision of a phase of a statewide program designed to furnish medical care benefits to eligible recipients of the Rhode Island State Medical Assistance Program; and to do related work as required. SUPERVISION RECEIVED: Works under the general direction of a superior with wide latitude for the use of independent judgement; work is reviewed for conformance to law, policy, rules and regulations. SUPERVISION EXERCISED: Plans and supervises the work of subordinates engaged in carrying out a phase of a State Medical Care Program; reviews work in process and upon completion for proficiency and conformance to laws and policies. ILLUSTRATIVE EXAMPLES OF WORK PERFORMED: To be responsible for the supervision of a phase of a statewide program designed to furnish medical care benefits to eligible recipients of the Rhode Island State Medical Assistance Program. To plan, assign and review the work of a professional and/or clerical staff engaged in processing for payment, in accordance with prescribed regulations, bills from the providers of: in-patient hospital services, out-patient hospital services, (clinic, accident room, diagnostic and therapeutic x-rays, pharmacy), physicians' services, drugs, dental services, optometric services, other laboratory and x-ray services, surgical appliances, visiting nurses services, podiatry services, ambulance service, skilled nursing home care, and intermediate care. To rule on the validity of claims which present unique problems involving authorization for medical benefits. To discern the inadequacies of the program, or of procedures in certain areas, and to recommend the needed corrections or additions. To be responsible for reconciling discrepancies and irregularities as well as continuous or aggravated violations involving charges, rules and regulations, standards or procedures relating to the provisions of the Rhode Island Medical Assistance Program. To comprehend the function and availability of community health resources and facilities and to coordinate their utilization by the Social Service staff in conjunction with the Medical Care Program. To assist in the operation of a program of orientation, information and consultation designed to acquaint social welfare staff, local directors of public welfare, professional consultants, advisory committees and other interested parties with the philosophy, objectives and operations of the Rhode Island Medical Assistance Program. To be responsible for the compilation of statistics and preparation of special reports concerning the operation of the Medical Care Program. To do related work as required.

Requirements

A thorough knowledge of the provisions of the state plan for medical assistance as it relates to in-patient hospital services, nursing and intermediate care services, visiting nurse services, and pharmacy services; the ability to interpret and apply such knowledge; a thorough knowledge of community health resources and facilities and the ability to coordinate their utilization by the Social Welfare staff in conjunction with the Medical Care Program; the ability to plan, assign and review the work of subordinates; the ability to organize and conduct a program of orientation, information and consultation involving the philosophy, objectives and operations of the Rhode Island Medical Assistance Program; the ability to maintain good relations with associates and the public; and related capacities and abilities.
Education: Such as may have been gained through: graduation from a college of recognized standing; and Experience: Such as may have been gained through: employment as a Medical Care Specialist; or in a responsible supervisory position in the areas of Medical Care Administration, Hospital Administration, Public Administration, Social Welfare, or in a Health or Accident Insurance Program which included the reconciliation of discrepancies, irregularities, and violations of law or standards or procedures in the processing of claims.
Or, any combination of education and experience that shall be substantially equivalent to the above education and experience.

Nice To Haves

Experience with oversight of human services programs serving older adults and adults with disabilities.
Excellent communication, writing, and documentation skills.
Ability to learn and work with computer systems and basic computer programs, such as Microsoft Office.
Experience with RI Bridges, MMIS, and WellSky preferred.
Knowledge of Medicaid eligibility and programs preferred.

Responsibilities

To be responsible for the supervision of a phase of a statewide program designed to furnish medical care benefits to eligible recipients of the Rhode Island State Medical Assistance Program.
To plan, assign and review the work of a professional and/or clerical staff engaged in processing for payment, in accordance with prescribed regulations, bills from the providers of: in-patient hospital services, out-patient hospital services, (clinic, accident room, diagnostic and therapeutic x-rays, pharmacy), physicians' services, drugs, dental services, optometric services, other laboratory and x-ray services, surgical appliances, visiting nurses services, podiatry services, ambulance service, skilled nursing home care, and intermediate care.
To rule on the validity of claims which present unique problems involving authorization for medical benefits.
To discern the inadequacies of the program, or of procedures in certain areas, and to recommend the needed corrections or additions.
To be responsible for reconciling discrepancies and irregularities as well as continuous or aggravated violations involving charges, rules and regulations, standards or procedures relating to the provisions of the Rhode Island Medical Assistance Program.
To comprehend the function and availability of community health resources and facilities and to coordinate their utilization by the Social Service staff in conjunction with the Medical Care Program.
To assist in the operation of a program of orientation, information and consultation designed to acquaint social welfare staff, local directors of public welfare, professional consultants, advisory committees and other interested parties with the philosophy, objectives and operations of the Rhode Island Medical Assistance Program.
To be responsible for the compilation of statistics and preparation of special reports concerning the operation of the Medical Care Program.
To do related work as required.

Benefits

For information regarding the benefits available to State of Rhode Island employees, please visit the Office of Employee Benefits' website at http://www.employeebenefits.ri.gov/.
Also, be advised that a new provision in RI General Law 35-6-1 was enacted requiring direct deposit for all employees. Specific to new hires, the law requires that all employees hired after September 30, 2014 participate in direct deposit. Accordingly, any employee hired after this date will be required to participate in the direct deposit system. At the time the employee is hired, the employee shall identify a financial institution that will serve as a personal depository agency for the employee.

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