See Medical Program Specialist 1, 162E

This is the senior or lead worker level of the series. Leads policy development, healthcare or health services program evaluation, outreach and education, or contract administration.

Positions work under general direction as a senior-level professional leading other professional staff engaged in the review, analysis, and monitoring of health care best practices and cost containment programs.  Positions independently develop, plan, evaluate, promulgate policies and provide consultative services to medical providers and/or department staff regarding program administration.

Leads staff or committees engaged in the review, analysis, and monitoring of health care program effectiveness and cost effectiveness program operations; 

Monitors performance of staff or workgroups and provides technical assistance concerning interpretation of medical policy and procedures, program analysis, and monitoring activities; 

Conducts in-depth review of medical coding issues; gathers data, identifies trends, and makes recommendations on process development, policy development, and communications, outreach and education for medical diagnostic coding; 

Plans, develops and evaluates time-limited studies for the review, analysis, and monitoring of health care cost containment programs; prepares reports on the time-limited studies on of health care effectiveness programs; 

Develops and coordinates implementation of program initiatives with division staff and/or staff from other program areas; 

Responds to inquiries from and prepares summary and status reports for Legislature, upper level division management, medical provider associations, other State agencies, and other interested parties;  

May supervise medical diagnostic coders; 

Reviews and evaluates State regulations, practices of other states, and publications for potential applicability to the health care programs and health care cost containment programs; 

Coordinates the development, interpretation and implementation of health care management, effectiveness, and cost policies; promulgates administrative and procedural regulations for program implementation;  

Provides technical and consultative assistance to medical providers, and/or department staff, regarding the health care programs and cost containment programs;  

Designs complex reporting systems; prepares instructions and develops training plans;  

Participates in research studies pertinent to the development of health care cost containment programs; 

Plans and develops strategy for analysis and reporting on medical providers and/or injured workers' utilization of medical services; 

Plans and develops strategy for analysis and reporting on medical provider delivery or injured worker utilization of medical services; 

Coordinates, develops and implements orientation and training needs for staff and medical providers; develops manuals and procedures; 

Performs other work as required;

Knowledge of:  State policies and regulations related to health care programs; principles and practices of program planning and evaluation; current trends and economic problems relating to health care cost; health care organizations and industry; principles of supervision and staff development; the legislative process.  

Ability to:  develop, organize and direct programs; work effectively with program staff, providers, and other affected parties; analyze, interpret, and resolve complex problems related to health care cost programs; communicate clearly and effectively both orally and in written form; train others.

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.

Persons legally authorized to work in the U.S. under federal law, including Deferred Action for Childhood Arrivals recipients, are eligible for employment unless prohibited by other state or federal law.

One-year experience as a Medical Program Specialist 1. 

OR 

A Master's degree with major study in public health, public administration, nursing, health administration, economics, business administration, or closely allied field and two years of supervisory or consultative experience in a health services program.    

Two additional years of qualifying experience may be substituted for the Master's  degree provided a Bachelor's the degree in one of the above fields has been achieved. 

Note: For positions leading or supervising staff performing medical coding work, a Certified Professional Coder (CPC) certification, or equivalent, may be required.

 

Revised Legal Requirements; effective June 6, 2024, due to adopted legislative action.